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DR. TED ROTHSTEIN BROOKLYN ORTHODONTIST

[Diagnosis of Snoring and Obstructive Sleep Apnea (OSA)]

See photos to Dr. Ted wearing a TSD (Tongue Stabilizing Device)

Date of procedure: May 24, 2000,

The actual experience of Dr. Ted Rothstein with somnoplasty procedure performed by Dr. Dan Arick*

SOMNOPLASTY TO ELIMINATE SNORING

(The non-surgical, in-office treatment for alarming snoring not related to sleep apnea)

INTRODUCTION:

Most snoring is caused by the soft tissue of the palate vibrating violently as the sleeper breathes in. Snoring can be violently and alarmingly loud. The one who snores will often completely deny and scoff at their spouse when told that they snore because their snoring, strangely enough, does not wake them up. Of course the non-snoring spouse can put noise "stopple" in their ears. However the noise of snoring can be so over powering that not even that preventive measure helps. In my case my wife had an ear infection earlier in life that prevented her from stuffing her ears with anything. My snoring was getting progressively worse not withstanding the fact that I was wearing a snoring device that had been 85% effective for the past ten years. Then I heard about a new procedure called somnoplasty which was a technically new, minimally invasive, non-surgical, in-office approach to the snoring problem with a relatively high success rate. Compared to the surgical approaches, somnoplasty seemed like a breeze and that is exactly what it turned out to be. Briefly it works like this: A probe is inserted about an inch into the tissue of the most rear part of the soft palate. The probe is set to deliver sufficient heat energy to cause the tissue around the probe to be devitalized. The devitalized tissue shrinks over a period of 4-6 weeks and causes the part of the palate that vibrates most when you snore to stiffen and be less floppy.

PRIOR TO THE PROCEDURE:

Dr. Arick examines mouth, palate and throat to determine the suitability of the patient for the procedure using the Mallampiti classification for the seriousness of the airway obstruction.

Dr. Arick prescribes two medicines to begin the day of and prior to the somnoplasty office procedure:

    1. Steroid pills to prevent/minimize swelling (Methylprednisolone 4mg tabs taken according to special instructions on pack).
    2. Antibiotic (Cephalexin 500 mg caps)
    3. I began both meds at 1pm (3 hours before the somnoplasty procedure)

      THE SOMNOPLASTY PROCEDURE:

      The procedure was carried out at 4:00 p.m. on me as outlined below.

      In my case the local anesthesia wore off in about 3 hours and my throat (toward the back of my mouth) began to hurt, especially on swallowing, sufficiently such that I took 2 Advil (Motrin, Ibuprofen) to relieve it I would describe that pain on a scale of 1-10 as a 5/10. In my case: An hour later the pain receded to 5/10. Just before going to sleep I took one Darvocet (non-narc analgesic). My snoring was so loud that I awakened myself something that my wife usually does for me. But this time she was away. I slept on pillows with my head raised 45 degrees. I had worn an anti-snoring device before the procedure so I put that back in my mouth and it helped.

      I awoke with no pain and continued taking my antibiotic and steroid medicines. I was more aware of some difficulty (but only mildly uncomfortable) swallowing during the day. Those of you are interested in obtaining more information may go to the website for details and literature on the subject. Finally, you can go to www.drted.com ("site additions") to see photographs of the in-office procedure done by Dr. Arick.

      The somnoplasty procedure is done at Dr. Arick's Manhattan office at 755 Park Avenue corner 72nd St. 718 624 0222 and takes 30 minutes. There are persons for whom this procedure is very suitable and some for whom it is not appropriate. An ENT specialist can advise you if you are a good candidate.

      Dr. Arick and nurse will to check to see that you are comfortable and prepared to have the somnoplasty procedure.

      You acknowledge that you have been provided with all the important information about this procedure including its risks by signing an "Informed Consent" document. This "permission to proceed" document can be obtained form the office well before the time of the procedure should you want to read it.

      Dr. Arick will establish his method of allowing you to signal him that you are comfortable during the procedure. (finger upraised)

      The nurse assistant prepares the standard settings on the somnoplasty machine for the delivery of the proper energy and temperature 85 Centigrade (185 degrees Fahrenheit) to the soft tissue of the palate, which is about the size of a large breadbox.

      She attaches your new sterile hand piece (energy delivering apparatus) to the machine, and then attaches electrical grounding tape to the skin on your lower back.

      The doctor/nurse gently sprays back of mouth with topical anesthetic to prevent or minimize the discomfort of the anesthetic injections you will receive to eliminate all possible pain arising from inserting the hand piece probe into the soft palate. (See picture of area of palate where injections to anesthetize palate are given.)

      The doctor will uses a special bending tool to shape the power delivery tip on the hand-piece to the exact shape of your palate.

      Dr Arick tests that the anesthesia is profound.

      Dr Arick painlessly inserts the tip of the hand-piece into the middle of the soft palate going up to and slightly into the uvula and delivers a painless stimulus to the tissues for about one minute and painlessly withdraws the tip from your soft palate and mouth. The  retractable tip of the handpiece is about 3/4'' long and no wider than a tailor's pin with a point smaller than the period at the end of this sentence.

      He does the same on the right and left side of the soft palate. (See diagram)

      The somnoplasty procedure is now completed.

      Nurse removes the electrical grounding tape from back

      Dr. and nurse and nurse check to see if patient is comfortable and feeling ok.

      You will leave the office about 45 minutes after arriving.

      POST SOMNOPLASTY TREATMENT INSTRUCTIONS

      Patient Instructions:

          1. You may experience a sore throat for 1-5 days which you can take Advil (Motrin, Ibuprofen) or Tylenol to relieve.
          2. The anesthesia takes about 2 hours to wear off. Then you will begin to experience pain/soreness. Sucking on icy cold water or liquids or flavored ice popsicles can bring temporary relief. But dairy products such as ice cream are not recommended because they may increase mucous production. Be cautious not to consume and hot liquids until the anesthesia wears off lest you unwittingly scald your mouth.
          3. You may experience a full feeling in the back of your mouth/throat. It is caused by the uvula (the part that dangles at the back of your palate) becoming longer (swelling) and lying on the far back of your tongue. The feeling will fade in 24-48 hours as the uvula begins to normalize, and shrink.
          4. If you experience swelling that concerns you call the office: 624 0222
          5. You should sleep propped up at 45 degrees the first night or even in a reclining chair.
          6. You may experience a temporary change in your voice after the procedure and maybe even for a few days after. It will return too normal.
          7. Snoring is usually worse during the first week
          8. During the second week snoring may become high-pitched. You (your spouse) may begin to notice brief periods when your snoring is noticeably diminished.
          9. Snoring will usually begin to diminish between the 4th and the 8th week post procedure. If you do not show significant improvement by 6-10 weeks, the somnoplasty procedure can be repeated until your snoring is controlled. You can call the office regarding fee for repeating the treatment.

We have given you a prescription for:

Minimizing copious saliva flow during the procedure.

Preventing/minimizing post procedure swelling.

Preventing post-procedure infections.

Eliminating pain/soreness.

CONCLUSION:

We have tried to make the stress and anxiety of this procedure done for you as minimal as possible. We hope we have succeeded and that you will have the pleasures that signal a rapid and uneventful recovery. Most of all we hope you and your spouse reap all the rewards that the elimination of snoring can bring. Please refer our office to your friends and relatives. We will be happy to provide you with the name of some patients who have been through this procedure.

Sincerely, Dr. Dan Arick and the Staff

Dr. Dan Arick is an ENT (ear nose and throat) specialist in exclusive practice for the past 23 years:

Brooklyn:
450 Clinton St. Entrance on 2nd St.
Tel. 718 624 0222
Manhattan:
755 Park Ave. Cor. 72nd St
Tel. 212 737 5517

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[Diagnosis of Snoring and Obstructive Sleep Apnea (OSA)]

POST SOMNOPLASTY PROCEDURE SNORING IMPROVEMENT PROGRESS REPORTS

Spouses rating: 0-3 Occasional or no snoring not bothersome to bed partner.
                                4-6 Persistent snoring bothersome to bed partner.
                                7-9 Persistent loud snoring frequently annoying to bed partner.
                                10  Heroic snoring not tolerated and snorer banished.

Somnoplasty procedure date:  Wednesday 5/24
Daily score to end of 1st week ending  Wed. May 31

         5/24    10 Discomfort swallowing:  Took 2 advil and 1 darvocet befor retiring
            5/25    10 Mild swallowing discomfort
            5/26    10 Swallowing discomfort gone, Uvula swollen causing uncomfortable feeling back of mouth
            5/27    10 Uncomfortable feeling diminishing as uvula swelling diminishes
            5/28    10 Normal feelings returning
            5/29    10Totally comfortable
            5/29    10
            5/30    10
          5/31   10 First few hours same bed then later banished
          6/1     10 Expelled
            6/2     10 Given the boot
            6/3     10 Hoping for some improvement (took a nap and my snoring woke ME up)
            6/4     0-3 BINGO!  Took 2 wiffs of Afrin (over-the-counter) in  each nostril before closing eyes;  NOTE: I am practicing breathing
                       with mouth open and simultaneously breathing through the nostrils and the mouth.
            6/5     0-3 BINGO again (Afrin as before)
            6/6     4-6, But no eviction notice given  (no Afrin; tried keeping head more raised)
            6/7     7-9, Exiled at 4 pm (no afrin)
            6/8     4-6, Didn't get the boot. Spouse heard a new sound... something like a click.
            6/9        5, Welcome sign was up.
            6/10    5-7, (10?) Snoring too much for spouse  from the  very onset of going to sleep. Spouse leaves tor other bedroom. Tried propping 
                      head up higher to no avail.
          6/11     10, No doubt about it (with afrin); began using the A/C in the bedroom three nights ago
            6/12       0 
            6/13    10?? Banished in the first hour, but spouse has no memory of being disturbed or asking me to make my exit.
            6/14-     3, No Afrin
            6/15-6/19 Spouse away
            6/19    3, Afrin
            6/20    0, No afrin  (spouse jet lagged and very tired)
            6/21    3, No afrin
            6/22    2-3
            6/23    4
            6/24    2-3
            6/25    7-8 Air conditioning?
            6/26    3-4 Have decided to repeat somnoplasty procedure. In addition have decided to have the uvula removed also at the same time
                        since it not only appears long to me but it sense its presence laying on the back of my tongue.
            6/27     2-3
            6/28-30 Spouse away
            7/1    10
            7/2    2-3
            7/3    10
            7/4    10
            7-5    3-4
            7/6-7/12    spouse away
           

   
       8/2/   I returned to the office and Dr. Arick repeated the somnoplasty procedure for the 2nd time as had been previously recommended. This time I started the steroid medicine the morning of the of the procedure (to minimize post-operative swelling). Pain/discomfort  was minimal as noted   previously and by the next day had largely disappeared.  My swollen uvula gave me the feeling that I needed to swallow but swallowing did not make the feeling disappear.  By 8/4 the  discomfort of the swallowing feeling was all but gone and I was 95% of my normal self.again.
        8/ 2-9    With all due respect to my experiences following the first somnoplasy procedure my spouse and I slept in separate bedrooms
           8-10   3-4
           8-11   2-3  I was introduced to the idea that shallower breathing was good to reduce snoring. (http://home.pacific.net.sg/~cdrake/)  So I                         bought some 3m micropore gauze and taped my mouth closed as was suggested. I was comfortable and slept very well. It  
                         was very interesting to discover that when I tried to create a snore  through my nose alone the snore was NOTICEABLY
                         MUTED AS COMPARED TO THE SNORE I COULD  CREATE WITH MY MOUTH OPEN. The reader has only to try it for
                          him/herself to prove that this is true.  
            8/12-13  Spouse away
            8/14-20  10 had to sleep almost every nite
           
8/21        0  Here is what I did:  I started using my "snoregard" again (the device that keeps my mouth open and my lower jaw propped forward about   1/4." This device had become ineffective.)  In addition this time I placed  two pieces of 3m micropore gauze to cover my nostril openings. In  effect I was forced to breathe in and solely through my mouth. However, the gauze did permit the passage of air through my nostrils in a kind  of muffled way. There was some excessive salivary flow and some mouth dryness, but the snoring was ENTIRELY GONE ALL NIGHT.  I   believe a number of variable were responsible. 1. The opening of the mouth opens the airway wider  which makes the palate more taut and  less likely to vibrate. (Try opening your mouth a little and make mouth snoring sounds; then open your mouth much wider and try making   snoring noises.) 2. My palate/uvula had become shorter/thicker as a result of the somnoplasties.  3. The act of mouth breathing may result   in decreasing the CO2 level in the blood and consequently may have "calmed" my the breathing inspirations.  4.  Mouth breathing seems to cause a drying of the mouth which further  stiffens the tissues which helps to minimize how they vibrate.
            8/22        0
            8/23-27   0-1   Reduced the number of pieces of 3m micropore gauze that  I was covering my nostrils with from 2 to 1. Excessive
                                 mouth dryness
                                 is an inconvenience but still worth  the reduction of snoring. Spouse is very pleased.  The 3m gauze encourages mouth
                                breathing but at the same time permits me (with a bit of difficulty)  to breath through my nose. The overall result is  forced
                                 mouth breathing. 
            8/27-9/2  0-1  Dry mouth from mouth breathing is bothersome. The micropore gauze make my nose itchy sometimes.
           
10/15/00   Begin newly deisigned TheraSnore removable, and now adjustable appliance. Will test efficacy when wife returns.


4/11/01   About 3 months ago I received a pamphlet from Great Lakes, an orthodontic lab and supply house introducing a new  anti-snoring device called a TSD (Tongue Stabilizing Device).  Here are photos of the device:

Side view of the TSD. ( Insertion view. Dr. Ted squeezing the plastic bulb of the TSD whole inserting his tongue. Upon releasing the bulb the TSD sucks on to the tongue.

 
The resting/sleeping position. Note the TSD is holding the tongue forward and keeping the mouth open (thereby opening the airway) and the back of the mouth to allow easy breathing. An alternative position is to have the TSD slightly pulled in to the mouth and the lips resting lightly on top of the "lip rests"   

When the TSD is on and at rest in the mouth it is very comfortable/comforting. These days it is the rare night that my spouse banishes me from her bed. You can see how it gently sucks your tongue partly out of your mouth, but since it is encased by the device the tongues stays moist and protected. If you put the TSD on with too much pressure your tongue will tell you and you can simply release and replace it by squeezing the bulb of the TSD.  If  you wear the TSD all night when you wake up the front of your tongue will be/feel somewhat swollen for 15 -30 minutes. 


          
           Interesting Communications and Post Procedure Thoughts:

A communication from Dr. Gail Demko,(5/29) a dentist who specializes in the treatment of sleep apnea and snoring with oral appliances, http://sleepapneadentist.com  correctly points out that even with more aggressive surgical techniques the frequency of return of snoring by the end of one year is distressingly high.  To which my response was as follows:  "The literature at the somnoplasty site notes the recidivism rate, as you well indicate... Be that as it may, I preferred to take my chances. If it works at all, then all to the good. And when it stops being effective given how innocuous the procedure is I'll repeat it.  If it makes my wife happier to have me share her bed, it's the least I can do to oblige" :-)

June 5th, 2000
 Hi: my name is Debbie Donovan  [ DDonovan@somnus.com]  and I am the Marketing Communications Manager
here at Somnus. I have reviewed the website location to which you directed
customer service and sales. Although I am not a clinician, I have had the
privilege of listening to Drs Lionel Nelson, Todd Kingdom and Rick Goulding
teach internet courses on the Somnoplasty(R) Procedure. Many times these
issues have been raised and what follows is a layman's set of questions I'd
be asking. Since you are a physician, [AN ORTHODONTIST] you intuitively understand how on an
individual basis anatomical variations contribute to disease conditions like
sleep-disordered breathing [ I DO].

1. Diagnostic work-up. It is known that not every patient is a candidate for
the Somnoplasty Procedure; however some clinicians are finding that the
procedure can be combined with other therapies to affect a good outcome. I
assume, based on the information on Sleep Apnea on your web site, that you
had a sleep study to determine that you didn't suffer from OSAS. [ I DIDN'T, I DON'T] Dr. Arick
must also have ruled out contributing obstructions from the lateral wall,
tonsils and tongue[ HE DID]. Do you have a "webbed" palate or a long uvula--they
could be contributing to your situation [HAD A LONG UVULA]. I also assume that your weight and
general physical condition are within normal ranges [YES:  5'10', 185 POUNDS].

2. Treatment protocol. I assume that Dr. Arick used the 3-lesion approach [HE DID]
and that after 10 weeks (you are only at week 2) he plans to treat a second
time, especially common in men. That is the protocol that seems to produce
the best outcomes (85.3% success as defined by a subjective score of 3 or
less by your bedpartner). You mention in your daily post that you used
Afrin, has Dr. Arick treated your turbinates yet? [NO PROBLEM  WITH TURBINATES] Sounds like nasal
obstruction may also be contributing to your snoring [DON'T THINK SO].

All things considered, you might want to revisit any issue I've brought up
with Dr. Arick to see how it applies in your situation. You may also want to
sign up for one of our Somnoplasty Courses offered on the internet (email
your fax number so I can send you a registration form). I hope that you end
up in the "success" group and that you are pleased with your experience. Be
well, and hope to hear from you.

Thanks,
Deb

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[Diagnosis of Snoring and Obstructive Sleep Apnea (OSA)]