Sleep surgery

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Sleep surgery
Other namessleep apnea surgery

Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.

Contents

Definitions

Obstructive sleep apnea or sleep apnea is defined as either cessation of breathing (apnea) for 10 seconds, or a decrease in normal breathing (hypopnea) with an associated desaturation in oxygen and arousal during sleep that lasts at least 10 seconds. In adults, it is typical to have up to 4.9 events per hour. In obstructive sleep apnea, affected individuals are categorized based on how many apneas or hypopneas (apnea-hypopnea index or AHI) or events they have per hour.

The Wisconsin Sleep Cohort Study, a longitudinal study of the natural history of obstructive sleep apnea (OSA), found that of a random sample (602 employed men and women, 30–60 years old) the prevalence of OSA (5 or more events/hr) was 9% for women and 24% for men. However, the study found that among sleepy patients in this group, 2% of women and 4% of men met criteria for obstructive sleep apnea syndrome (OSAS). Those who snored habitually, were more likely to have an AHI of 15 or more. [1]

No airway obstruction during sleep. New no obstruction.png
No airway obstruction during sleep.
Airway obstruction during sleep. Airway obstruction.png
Airway obstruction during sleep.

Clinical results

Most obstructive sleep apnea sufferers have multiple points of obstruction in their airway and therefore require multilevel sleep surgery in order to maximize the efficacy of treatment. A systematic review of the literature and meta-analysis showed that multilevel sleep surgery achieves a 60.3% apnea hypopnea index (AHI) reduction. [2] This reduction in sleep apnea severity via surgical means compares well against the AHI reduction for best case CPAP patients where an overall AHI reduction of 66% was achieved. [3] Even single level surgical intervention in sleep apnea, which demonstrates a lesser degree of AHI reduction, showed a 31% survival benefit when compared against those using CPAP as therapy. [4]

In children

Children with obstructive sleep apnea typically have enlarged tonsils and adenoid tissue. Surgery on children is over 80% successful by simply performing an adenoidectomy and tonsillectomy. Those less likely to benefit from an adenotonsillectomy are obese children and those with other medical problems, such as Down Syndrome. [5]

A sub-group of children may have occult laryngomalacia, where the tissue directly above the vocal cords (epiglottis, arytenoids) collapses into the airway during sleep. [6] These children may benefit from a supraglottoplasty to help prevent that tissue from collapsing into the airway.

Surgical procedures

In adults, various surgeries treat specific causes for nasal and soft palate.

Obstruction in adults is most often multiple level, so the most successful surgeries involve multi-level surgery.[ citation needed ]

Tonsillectomy and/or adenoidectomy

Some adults with large tonsils may be candidates for having their tonsils and/or adenoids removed either alone or in combination with other procedures, such as uvulopalatopharyngoplasty (UPPP) or nasal surgery.

Uvulopalatopharyngoplasty (UPPP)

The procedure most commonly performed for sleep apnea is the uvulopalatopharyngoplasty (UPPP). This involves removal of the tonsils if still present, and a subsequent palatal procedure. The tonsil pillars are often sutured closed—and the uvula is either trimmed, cut, folded, reshaped, or sutured to the soft palate. [7] Studies have shown that treatment effect of UPPP with tonsillectomy increases with tonsil size. [8]

Uvulopalatopharyngoplasty. A) pre-operative, B) original UPPP, C) modified UPPP, and D) minimal UPPP. UPPP. 4 figures..png
Uvulopalatopharyngoplasty. A) pre-operative, B) original UPPP, C) modified UPPP, and D) minimal UPPP.

Hyoid suspension

Hyoid suspension, also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward in order to increase airway size and improve airway stability behind and below the base of tongue (retrolingual and hypopharyngeal region).[ citation needed ]

Genioglossus advancement

Genioglossus advancement (GA) also known as genial tubercle advancement (GTA), is a procedure that pulls the base of the tongue forward, usually to increase airway size due to deformity or a sleep breathing disorder. This procedure is frequently performed with either uvulopalatopharyngoplasty or maxillomandibular advancement surgeries.

Airway before genioglossus advancement. Genioglossus advancement before surgery.png
Airway before genioglossus advancement.
Genioglossus advancement after the surgery. Genioglossus advancement after osteotomy.png
Genioglossus advancement after the surgery.

Tongue muscles (genioglossus, geniohyoid and others) are attached to the lower jaw below the teeth. During a genioglossus advancement procedure, the surgeon cuts a small window or bone cut in the front part of the lower jaw (mandible) at the level of the geniotubercle where the genioglossus muscle attaches. This piece of bone, along with the attachment for the tongue (genial tubercle) is pulled forward and subsequently secured to the lower jaw, usually with a single screw or with a plate and screws.

This procedure is often combined with other surgeries such as uvulopalatopharyngoplasties or maxillomandibular advancement surgeries. It is rare to have this procedure performed as the only surgical treatment for sleep apnea, as obstruction in sleep apnea is most often at multiple levels (nose, palate, tongue, etc.).

Maxillomandibular advancement

Maxillomandibular advancement (MMA) or orthognathic surgery, also sometimes called bimaxillary advancement (bi-max), or maxillomandibular osteotomy (MMO), is a procedure that moves the upper jaw (maxilla) and the lower jaw (mandible) forward. The procedure was first used to correct deformities of the facial skeleton, including malocclusion. In the late 1970s, advancement of the lower jaw (mandibular advancement) improved sleepiness in three patients.[ citation needed ] Subsequently, maxillomandibular advancement was used for patients with obstructive sleep apnea.

Maxillomadibular advancement. Maxillomadibular advancement.png
Maxillomadibular advancement.

Currently, surgeons often perform maxillomandibular advancement surgery simultaneously with genioglossus advancement (tongue advancement). The genioglossus advancement pulls the tongue forward to decrease the amount of tongue blockage during sleep. MMA is one of the most effective surgical treatments for sleep apnea, with a high success rate. Nonetheless, the procedure is often used after other forms of treatment have failed (nasal surgeries, tonsillectomy, uvulopalatopharyngoplasty, tongue reduction surgeries). There is a longer recovery when compared to other sleep apnea surgeries, since the bones of the face have to heal into their new position. [9]

Tracheostomy

Tracheostomy is the only surgical procedure that completely bypasses the upper airway. This procedure was commonly performed in the 1960-1980's for obstructive sleep apnea, until other procedures such as the uvulopalatopharyngoplasty, hyoid suspension, genioglossus advancement, and maxillomandibular advancement surgeries were described as alternative surgical modalities for OSA.

Tracheostomy, bypassing area of airway obstruction during sleep. Tracheostomy with no further obstruction of airflow.png
Tracheostomy, bypassing area of airway obstruction during sleep.

Therapy alternatives

Continuous positive airway pressure

In 1981, Dr. Sullivan and colleagues introduced continuous positive airway pressure (CPAP), which replaced tracheostomy as the gold standard treatment for obstructive sleep apnea. CPAP machines are specially designed to deliver a constant flow or pressure. Some CPAP machines have other features as well, such as heated humidifiers. CPAP is the most effective treatment for obstructive sleep apnea, in which the pressure from CPAP prevents the airway from collapsing or becoming blocked. [10]

Patient using a CPAP machine. There are many models of CPAP face masks. Cpapanwender.jpg
Patient using a CPAP machine. There are many models of CPAP face masks.

Mandibular advancement device

A mandibular advancement device or mandibular advancement splint may be used in select patients as treatment for mild or moderate OSA. Where appropriate, they are considered a good therapy choice as they are non-invasive, easily reversible, quiet, and generally well accepted by the patient. The focus of improvement in appliance design is in reducing bulk, permitting free jaw movement (i.e., yawning, speaking, and drinking), and allowing the user to breathe through their mouth (early "welded gum shield"-type devices prevented oral breathing).

Over the last decade, there has been a significant expansion in the evidence base supporting the use of oral devices in the treatment of OSA. [11] Robust studies demonstrating their efficacy have been underpinned by increasing recognition of the importance of upper airway anatomy in the pathophysiology of OSA. [12] Oral devices have been shown to have a beneficial effect in targeting a number of significant clinical end points. These include the polysomnographic indexes of OSA, subjective and objective measures of sleepiness, blood pressure, aspects of neuropsychological functioning, and quality of life. Elucidation of the mechanism of action of oral devices has provided insight into the factors that predict treatment response and may improve the selection of patients for this treatment modality. [13] A further study by Dr. Edmund Rose, University of Freiburg (2004), successfully treated (AHI < 5) 88% of patients with MAS and proposes optimum patient selection to include AHI < 25, BMI < 30, and good dentition. [14]

Another study published in Sleep (2008) on the influence of nasal resistance (NAR) on oral device treatment outcome in OSA demonstrates the need for an interdisciplinary approach between ENT surgeons and sleep physicians to treating OSA. The study suggests that higher levels of NAR may negatively affect outcome with MAS [15] and subsequently methods to lower nasal resistance may improve the outcome of oral device treatment.

A mandibular advancement splint for treatment of sleep apnea. Mandibular advancement splint.jpg
A mandibular advancement splint for treatment of sleep apnea.
A different style of mandibular advancement splint. Avance mandibular.jpg
A different style of mandibular advancement splint.

Tongue retaining device

Tongue retaining devices are devices that can be placed in a manner such that the tongue is kept in a forward position. These devices have been used for snoring and obstructive sleep apnea. [16]

Tongue Retaining Device Tongue Retaining Device.tif
Tongue Retaining Device

Tongue retaining devices hold the tongue in place by either suction, a fixed bar, or a custom dental impression. Hybrid devices combine mandibular advancement with the tongue restraint. [17] Tongue retaining devices have not been well-received as a therapy choice since they are invasive, and the acclimation period is long. [18] The devices have shown high success rates for therapy in studies published in Behaviour Research and Therapy [19] and the Journal of Clinical Sleep Medicine . [20]

Related Research Articles

<span class="mw-page-title-main">Otorhinolaryngology</span> Medical specialty

Otorhinolaryngology ( oh-toh-RY-noh-LARR-in-GOL-ə-jee, abbreviated ORL and also known as otolaryngology, otolaryngology – head and neck surgery, or ear, nose, and throat is a surgical subspeciality within medicine that deals with the surgical and medical management of conditions of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, head and neck surgeons, or ENT surgeons or physicians. Patients seek treatment from an otorhinolaryngologist for diseases of the ear, nose, throat, base of the skull, head, and neck. These commonly include functional diseases that affect the senses and activities of eating, drinking, speaking, breathing, swallowing, and hearing. In addition, ENT surgery encompasses the surgical management of cancers and benign tumors and reconstruction of the head and neck as well as plastic surgery of the face, scalp, and neck.

<span class="mw-page-title-main">Sleep apnea</span> Disorder involving pauses in breathing during sleep

Sleep apnea, also spelled sleep apnoea, is a sleep disorder in which pauses in breathing or periods of shallow breathing during sleep occur more often than normal. Each pause can last for a few seconds to a few minutes and they happen many times a night. In the most common form, this follows loud snoring. A choking or snorting sound may occur as breathing resumes. Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. In children, it may cause hyperactivity or problems in school.

<span class="mw-page-title-main">Snoring</span> Vibratory sound made while asleep

Snoring is the vibration of respiratory structures and the resulting sound due to obstructed air movement during breathing while sleeping. The sound may be soft or loud and unpleasant. Snoring during sleep may be a sign, or first alarm, of obstructive sleep apnea (OSA). Research suggests that snoring is one of the factors of sleep deprivation.

<span class="mw-page-title-main">Obesity hypoventilation syndrome</span> Condition in which severely overweight people fail to breathe rapidly or deeply enough

Obesity hypoventilation syndrome (OHS) is a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels. The syndrome is often associated with obstructive sleep apnea (OSA), which causes periods of absent or reduced breathing in sleep, resulting in many partial awakenings during the night and sleepiness during the day. The disease puts strain on the heart, which may lead to heart failure and leg swelling.

<span class="mw-page-title-main">Positive airway pressure</span> Mechanical ventilation in which airway pressure is always above atmospheric pressure

Positive airway pressure (PAP) is a mode of respiratory ventilation used in the treatment of sleep apnea. PAP ventilation is also commonly used for those who are critically ill in hospital with respiratory failure, in newborn infants (neonates), and for the prevention and treatment of atelectasis in patients with difficulty taking deep breaths. In these patients, PAP ventilation can prevent the need for tracheal intubation, or allow earlier extubation. Sometimes patients with neuromuscular diseases use this variety of ventilation as well. CPAP is an acronym for "continuous positive airway pressure", which was developed by Dr. George Gregory and colleagues in the neonatal intensive care unit at the University of California, San Francisco. A variation of the PAP system was developed by Professor Colin Sullivan at Royal Prince Alfred Hospital in Sydney, Australia, in 1981.

Upper airway resistance syndrome (UARS) is a sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The symptoms include unrefreshing sleep, fatigue, sleepiness, chronic insomnia, and difficulty concentrating. UARS can be diagnosed by polysomnograms capable of detecting Respiratory Effort-related Arousals. It can be treated with lifestyle changes, orthodontics, surgery, or CPAP therapy. UARS is considered a variant of sleep apnea, although some scientists and doctors believe it to be a distinct disorder.

<span class="mw-page-title-main">Polysomnography</span> Multi-parameter study of sleep and sleep disorders

Polysomnography (PSG), a type of sleep study, is a multi-parameter study of sleep and a diagnostic tool in sleep medicine. The test result is called a polysomnogram, also abbreviated PSG. The name is derived from Greek and Latin roots: the Greek πολύς, the Latin somnus ("sleep"), and the Greek γράφειν.

<span class="mw-page-title-main">Mandibular advancement splint</span>

A mandibi splint or mandibi advancement splint is a prescription custom-made medical device worn in the mouth used to treat sleep-related breathing disorders including: obstructive sleep apnea (OSA), snoring, and TMJ disorders. These devices are also known as mandibular advancement devices, sleep apnea oral appliances, oral airway dilators, and sleep apnea mouth guards.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

<span class="mw-page-title-main">Uvulopalatopharyngoplasty</span>

Uvulopalatopharyngoplasty is a surgical procedure or sleep surgery used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may typically be removed include:

<span class="mw-page-title-main">Maxillomandibular advancement</span> Type of jaw surgery

Maxillomandibular advancement (MMA) or orthognathic surgery, also sometimes called bimaxillary advancement (Bi-Max), or maxillomandibular osteotomy (MMO), is a surgical procedure or sleep surgery which moves the upper jaw (maxilla) and the lower jaw (mandible) forward. The procedure was first used to correct deformities of the facial skeleton to include malocclusion. In the late 1970s advancement of the lower jaw was noted to improve sleepiness in three patients. Subsequently, maxillomandibular advancement was used for patients with obstructive sleep apnea.

Genioglossus advancement (GA) is a surgical procedure or sleep surgery in which the base of the tongue is pulled forward. It is usually to increase airway size due to deformity or a sleep breathing disorder. This procedure is frequently performed with either uvulopalatopharyngoplasty or maxillomandibular advancement surgeries.

Hypopnea is overly shallow breathing or an abnormally low respiratory rate. Hypopnea is defined by some to be less severe than apnea, while other researchers have discovered hypopnea to have a "similar if not indistinguishable impact" on the negative outcomes of sleep breathing disorders. In sleep clinics, obstructive sleep apnea syndrome or obstructive sleep apnea–hypopnea syndrome is normally diagnosed based on the frequent presence of apneas and/or hypopneas rather than differentiating between the two phenomena. Hypopnea is typically defined by a decreased amount of air movement into the lungs and can cause oxygen levels in the blood to drop. It commonly is due to partial obstruction of the upper airway.

<span class="mw-page-title-main">Continuous positive airway pressure</span> Form of ventilator which applies mild air pressure continuously to keep airways open

Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The application of positive pressure may be intended to prevent upper airway collapse, as occurs in obstructive sleep apnea, or to reduce the work of breathing in conditions such as acute decompensated heart failure. CPAP therapy is highly effective for managing obstructive sleep apnea. Compliance and acceptance of use of CPAP therapy can be a limiting factor, with 8% of people stopping use after the first night and 50% within the first year.

Nasal expiratory positive airway pressure is a treatment for obstructive sleep apnea (OSA) and snoring.

A sleep-related breathing disorder is a sleep disorder in which abnormalities in breathing occur during sleep that may or may not be present while awake. According to the International Classification of Sleep Disorders, sleep-related breathing disorders are classified as follows:

Long face syndrome, also referred to as skeletal open bite, is a relatively common condition characterised by excessive vertical facial development. Its causes may be either genetic or environmental. Long face syndrome is "a common dentofacial abnormality." Its diagnosis, symptomology and treatments are complex and controversial. Indeed, even its existence as a "syndrome" is disputed.

Hyoid suspension, also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure or sleep surgery in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and hypopharyngeal airway. The horseshoe shaped hyoid bone sits directly below the base of tongue with the arms of the bone flanking the airway. Hyoid suspension is typically performed as a treatment for obstructive sleep apnea (OSA). This procedure is frequently performed with a uvulopalatopharyngoplasty (UPPP) which targets sites of obstruction higher in the airway. Typically, a hyoid suspension is considered successful when the patient's apnea-hypopnea index is significantly reduced after surgery.

Oral pressure therapy (OPT) is a treatment for obstructive sleep apnea (OSA) that uses negative pressure in the mouth to shift the soft palate and tongue forward. The negative pressure is created by a bedside console connected by a small tube to a mouthpiece worn inside the mouth during sleep. The device is successful in between a quarter and a third of people.

TransOral Robotic Surgery (TORS) is a modern surgical technique used to treat tumors of the mouth and throat via direct access through the mouth. TransOral Robotic Sleep Apnea (TORSA) surgery utilizes the same approach to open the upper airway of patients with obstructive sleep apnea. In TORS and TORSA procedures, the surgeon uses a surgical robot to view and access structures in the oral cavity (mouth) and pharynx (back of the throat) without any incisions through the neck, chin or lip (these incisions are necessary in traditional, non-robotic approaches). Current TORS techniques include radical tonsillectomy, resection of palate and base of skull tumors, hemiglossectomy and resection of tumors above and involving the larynx. The TORSA technique is used for uvulopalatopharyngoplasty, hemiglossectomy, and other airway procedures.

References

  1. ↑ Young, T; Palta, M; Dempsey, J; Skatrud, J; Weber, S; Badr, S (1993). "The occurrence of sleep-disordered breathing among middle-aged adults". The New England Journal of Medicine. 328 (17): 1230–1235. doi: 10.1056/nejm199304293281704 . PMID   8464434. S2CID   9183654.
  2. ↑ Lin, HC; Friedman, M; Chang, HW; Gurpinar, B (May 2008). "The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome". Laryngoscope. 118 (5): 902–8. doi: 10.1097/MLG.0b013e31816422ea . PMID   18300704. S2CID   205811023.
  3. ↑ Stuck, BA; Leitzbach, S; Maurer, JT (Jun 2012). "Effects of continuous positive airway pressure on apnea-hypopnea index in obstructive sleep apnea based on long-term compliance". Sleep Breath. 16 (2): 467–71. doi:10.1007/s11325-011-0527-8. PMID   21590521. S2CID   24042324.
  4. ↑ Weaver, EM; Maynard, C; Yueh, B (2004). "Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery". Otolaryngol Head Neck Surg. 130 (6): 659–65. doi:10.1016/j.otohns.2003.12.012. PMID   15195049. S2CID   705834.
  5. ↑ Chan, DK; Jan, TA; Koltai, PJ (2012). "Effect of obesity and medical comorbidities on outcomes after adjunct surgery for obstructive sleep apnea in cases of adenotonsillectomy failure". Archives of Otolaryngology–Head & Neck Surgery. 138 (10): 891–896. doi: 10.1001/2013.jamaoto.197 . PMID   23069817.
  6. ↑ Chan, DK; Truong, MT; Koltai, PJ (2012). "Supraglottoplasty for occult laryngomalacia to improve obstructive sleep apnea syndrome". Archives of Otolaryngology–Head & Neck Surgery. 138 (1): 50–54. doi: 10.1001/archoto.2011.233 . PMID   22249629.
  7. ↑ Yousuf, Aamir (2013). "Clinical Predictors for Successful Uvulopalatopharyngoplasty in the Management of Obstructive Sleep Apnea". International Journal of Otolaryngology. 2013: 290265. doi: 10.1155/2013/290265 . PMC   3793315 . PMID   24171001.
  8. ↑ Tschopp, Samuel; Tschopp, Kurt (2019). "Tonsil size and outcome of uvulopalatopharyngoplasty with tonsillectomy in obstructive sleep apnea". The Laryngoscope. 129 (12): E449–E454. doi:10.1002/lary.27899. ISSN   1531-4995. PMID   30848478. S2CID   73503702.
  9. ↑ Liu, Stanley Yung-Chuan (2015). "Lateral Pharyngeal Wall Tension After Maxillomandibular Advancement For Obstructive Sleep Apnea Is A Marker For Surgical Success: Observations From Drug-Induced Sleep Endoscopy". Journal of Oral and Maxillofacial Surgery. 73 (8): 1575–82. doi:10.1016/j.joms.2015.01.028. PMID   25843814.
  10. ↑ "General Information about Sleep Apnea Machines". Cpap-machine-reviews.com. Retrieved 3 November 2014.
  11. ↑ "SomnoMed - The Leader in Continuous Open Airway Therapy". SomnoMed. Retrieved 3 November 2014.
  12. ↑ Chan, A; Lee, R; Cistulli, PA (Aug 2007). "Oral Appliances for Obstructive Sleep Apnea". Chest. 132 (2): 693–9. doi:10.1378/chest.06-2038. PMID   17699143. S2CID   14252887.
  13. ↑ Chan, A; Lee, R; Cistulli, PA (Aug 2007). "Oral Appliances for Obstructive Sleep Apnea". Chest. 132 (2): 693–9. doi:10.1378/chest.06-2038. PMID   17699143. S2CID   14252887.
  14. ↑ Rose, E (2004). "Identifying the Ideal Oral Appliance Candidate". Journal of Orofacial Orthopedics. 65: 6.
  15. ↑ Zeng, B; Ng, AT; Qian, J; Petocz, P; Darendeliler, MAS; Cistulli, PA (2008). "Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea". Sleep. 31 (4): 543–547. doi:10.1093/sleep/31.4.543. PMC   2279749 . PMID   18457242.
  16. ↑ Lazard DS, Blumen M, Levy P, Chauvin P, Fragny D, Buchet I, Chabolle F. The tongue-retaining device: efficacy and side effects in obstructive sleep apnea syndrome. Journal of Clinical Sleep Medicine. 2009 Oct 15;5(5):431-8.
  17. ↑ "The Best Dental Snoring Mouthpiece: Types and Option". SomnoSure Education Center. Retrieved 30 January 2018.
  18. ↑ "Do Tongue Retaining Devices Work to Decrease Snoring?". SnoreNation. Retrieved 30 January 2018.
  19. ↑ Cartwright, Rosalind; Stefoski, Dusan; Caldarelli, David; Kravitz, Howard; Knight, Sara; Lloyd, Stephen; Samelson, Charles (1988). "Toward a treatment logic for sleep apnea: The place of the tongue retaining device". Behaviour Research and Therapy. 26 (2): 121–126. doi:10.1016/0005-7967(88)90111-8. PMID   3365202.
  20. ↑ Lazard, Diane S.; Blumen, Marc; Levy, Pierre; Chauvin, Pierre; Fragny, Dorothee; Buchet, Isabelle; Chabolle, Frederic (15 October 2009). "The Tongue-Retaining Device: Efficacy and Side Effects in Obstructive Sleep Apnea Syndrome". Journal of Clinical Sleep Medicine. 5 (5): 431–438. doi:10.5664/jcsm.27598. PMC   2762714 . PMID   19961027.
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