Sleep Apnea/Snoring

Sleep Apnea Treatment in San Antonio at Endormir Sleep and Sinus Institute

Is your partner’s snoring keeping you awake? Do you wake up feeling exhausted and irritable, even after a full night’s sleep? The solution to your problem could be a sleep apnea treatment with Dr. Jose Barrera or Dr. Nici Bothwell. With proper treatment, patients can significantly reduce the symptoms of this condition, for a safer, more comfortable sleep experience.

Dr. Barrera, a triple board-certified and fellowship trained surgeon, is also a fellowship director in Sleep Surgery and Facial Plastic and Reconstructive Surgery and a recognized International leader in the field of Sleep Medicine and Surgery.  Dr. Bothwell is dual-board certified in Otolaryngology-Head and Neck Surgery and Sleep Medicine, and is a specialist in sleep apnea. 

Dr. Barrera and Dr. Bothwell use the latest treatment methods and surgical techniques to bring patients relief, often enabling sleep apnea treatment without CPAP. 

If you’ve tried a CPAP machine and haven’t tolerated it well, or if you are seeking CPAP alternatives, come see us. Dr. Barrera and Dr. Bothwell are experts in sleep apnea and have brought nighttime relief to countless men and women throughout Texas. Endormir Sleep and Sinus Institute helps those coming from outside San Antonio and is recognized as a leading practice in Sleep Surgery in Texas.

Sleep apnea can be a complex issue, and solutions often vary from patient to patient. If you have questions about the right sleep apnea treatment options, don’t hesitate to call Endormir Sleep and Sinus Institute at 210-468-5426 in San Antonio, Texas. You can also reach out to us or to schedule a consultation via our online form

You may read about the latest publications that Dr. Barrera has authored here. Dr. Barrera has been a featured authored on Sleep Apnea and Skeletal surgery in these three textbooks.

What Is Sleep Apnea?

The word “apnea” is Greek, meaning “without breath.”

Sleep apnea is a sleep disorder that causes breathing to stop and start periodically throughout the night.

Patients with this condition are literally without breath at certain times during sleep. These breathing disturbances can happen many times each night and can last anywhere from 10 seconds to a minute or longer. Many patients will experience hundreds of instances of breathing cessation nightly. Most patients with this sleep disorder do not realize an apnea or pause in breathing is occurring. Other patients experience hypopnea or a drop in airflow causing an arousal or a drop in oxygenation. Both apneas and hypopneas can be dangerous if left untreated. The total apneas and hypopneas per hour is used as an index or apnea hypopnea index (AHI) to determine whether a patient is mild, moderate, or severe sleep apnea.

Sleep apnea can be a serious problem. It causes severe sleep disturbances for many patients, preventing them from reaching the deeper stages of sleep sufficiently. It can lower oxygen levels in the blood, depriving the brain and other organs of life-sustaining oxygen. Constant waking and restless sleep increase the body’s stress response, raising blood pressure and heart rate. Since patients don’t sleep well with sleep apnea, some fall asleep while driving and get into automobile accidents. Others find that they struggle at work, putting their careers, and sometimes their lives, in jeopardy.

There are three different types of sleep apnea. The most common type we see at Endormir Sleep and Sinus Institute is called Obstructive Sleep Apnea (OSA). This sleep disorder occurs when the muscles in the throat relax and block the airway during sleep.

You may be surprised to learn:

  • Obstructive sleep apnea is very common. Research indicates that approximately 24% of men and 9% of women have this syndrome.
  • Many patients with this condition do not realize they have it. As many as 93% of females and 82% of males with moderate to severe OSA are undiagnosed.
  • This condition can occur at any age, even childhood.
  • The effects of sleep apnea are serious. It has proven negative impact on the cardiovascular and respiratory systems, as well as cognitive function. OSA is associated with hypertension, heart failure, stroke, motor vehicle accidents, excessive daytime sleepiness, depression, arrhythmia, diabetes, and obesity.

Ready to reset your body to achieve your optimal health? Come see Dr. Barrera or Dr. Bothwell, both board certified sleep medicine experts. They can help you determine if you are affected by this condition. If you do have OSA, they’ll work with you to find sleep apnea treatment options so you can improve your health and finally get a good night’s sleep.

Do I Need Sleep Apnea Treatment in San Antonio, TX?

Before we can take steps toward finding sleep apnea solutions, first we must find the problem. We’ll start your treatment with a detailed patient evaluation. During your evaluation, we’ll discuss:

  • Complete health and medical history
  • Quality of life issues including daytime sleepiness, snoring, insomnia, unusual movement, sexual dysfunction, morning headache, memory problems, and depression
  • Sleep study, if needed
  • Airway evaluation using laryngoscopy and nasal endoscopy in the clinic.

Dr. Barrera and Dr. Bothwell use extensive medical and reported data to customize your sleep apnea treatment. Visit us at our South-Central Texas center for a consultation if you believe you may suffer from OSA.

Snoring and Sleep Apnea Sites of Obstruction

What Causes Snoring?

Loud snoring is very often associated with obstructive sleep apnea. Dr. Barrera or Dr. Bothwell may recommend a sleep study to rule out this condition. If you do have OSA, we can explore sleep apnea treatments. If you do not have OSA, but do snore, snoring treatments can provide relief. Treatments for snoring include:

  • Radio-frequency to the palate, tongue, or nasal turbinates
  • Palate operation
  • Pillar procedure
  • Functional septorhinoplasty

There are patients with airway narrowing which present with nasal obstruction due to a deviated septum, turbinate hypertrophy, or nasal valve insufficiency which have snoring and upper airway resistance syndrome. These patients may also have palate and tongue base enlargement causing narrowing of the upper airway. Although the sleep study may not overtly show an elevated apnea hypopnea index, patients with UARS have increased respiratory event related arousals. An thorough airway evaluation is necessary to rule out airway obstruction. UARS patients often present with snoring, excessive daytime sleepiness, and an elevated respiratory disturbance index or RDI.

Snoring is very common, affecting approximately 45% of all adults occasionally, 25% regularly. If you snore, call us for a consultation at 210-468-5426.

Sleep Apnea Treatment, San Antonio, TX- What Sleep Apnea Surgery Options Do We Offer at Endormir Sleep and Sinus Institute and Endormir Surgical?

Obstructive sleep apnea is a condition takes a heavy toll on health, well-being, and quality of life. The good news is that OSA usually treatable. Our sleep apnea surgery success rate is very high, and our patients are delighted by the significant improvements they experience after treatment. Link video of obstructive sleep apnea here (found in videos file)

Options for sleep apnea surgery include:

A floppy, elongated or thick soft palate and uvula can be responsible for the noise heard when snoring or the obstruction occurring during OSA. Palate surgery or uvulopalatopharyngoplasty uses different techniques to remove or reposition redundant tissues in the palate to open the airway. Palate surgery is usually very effective for treating snoring and OSA caused by a floppy soft palate.

Radiofrequency is a form of energy that is delivered to tissues to cause stiffening and volume reduction. Radiofrequency can be used to shrink the nasal turbinates, tighten the soft palate, or shrink the tongue base. This treatment is used on patients with snoring, nasal obstruction, and/or as a complementary procedure to other OSA treatments.

The genioglossus muscle is the primary muscle holding the tongue in position. It attaches to the internal aspect of the lower jaw. Genioglossus muscle advancement or GTA (geniotubercle advancement) places tension on the base of the tongue to open the airway. This can improve OSA and snoring.

Obstruction in the area behind the tongue plays an important role in OSA. This region is known as the hypopharynx. We achieve good outcomes by surgically targeting this area. Surgical procedures can be designed to make the tongue firmer and less collapsible during sleep or can remove tongue tissue such as the lingual tonsils.

Patients with a large tongue may benefit from a midline glossectomy, a procedure that removes a portion of the tongue. We perform this midline glossectomy on both adult and pediatric sleep apnea patients.

The hyoid is a U-shaped bone that lies just above the voice box. The hyoid is attached to the voice box and the tongue by muscular attachments. Hyoid suspension brings the hyoid forward. Advancing the hyoid will generally allow opening of the posterior airway space. This treatment can be used as a primary treatment, but usually complements other procedures.

MMA is performed to widen the entire upper airway space and minimize pharyngeal wall collapse. Of all the OSA treatments we offer, MMA has the highest sleep apnea surgery success rate with over 90% success in improving the apnea hypopnea index and resolving excessive daytime sleepiness. Maxillomandibular advancement is can also be performed to correct a malocclusion. We work with a team of orthodontists to achieve both skeletal and dental improvement in the airway and occlusion or bite.

         Dental Relationship Before                           Dental Relationship After 

Distraction osteogenesis with maxillary expansion (DOME) is a new surgical technique used in conjunction with orthodontic management to improve nasal breathing and help correct a transverse maxillary deficiency in patients with a narrowed jaw. DOME is best used for adult and pediatric patients with OSA. DOME is coupled with a maxillary expander. The DOME procedure opens up the nasal floor and improves breathing. Patients with a malocclusion, high arched palate and no evidence of soft tissue redundancy in the soft palate can benefit from this operation. DOME is performed at Texas Center for Facial Plastic and Laser Surgery under general anesthesia.  Maxillary expanders are secured at the same time as the DOME procedure. 

 

 

The Inspire® Implant, or a hypoglossal nerve stimulator, is inserted into the body to detect chest wall movement, artificially stimulating and contracting the genioglossus muscle. Inspire treats sleep apnea’s root cause, allowing for better sleep and no snoring. This will enable patients to breathe normally, and more importantly, sleep without a hose, mask, or machine. The FDA-approved sleep apnea device is quiet and can be turned on with a small remote.

Sleep Apnea FAQ’s

Sleep disordered breathing (SDB) is a spectrum of syndromes comprised by snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea (OSA). OSA is a syndrome not a disease and the specific etiology is unknown. However, it is largely secondary to anatomic upper airway narrowing during sleep and a yet unidentified central nervous system (CNS) component. Obstructive sleep apnea syndrome consists of periods of apneas (cessation of airflow at the nose or mouth for > 10 seconds) and hypopneas (reduced respiration with desaturation terminated by arousal). In general, OSA can be defined by the number of apneas and hypopneas per hour or apnea-hypopnea index (AHI). Mild OSA is defined as an AHI > 5 and < 15 but with symptoms of sleepiness. Moderate OSA is an AHI > 15, < 30 and severe OSA is an AHI > 30.

Common symptoms presenting as complaints from sleep apnea are snoring, pauses in breathing, morning headaches and nausea that result from the hypercarbia (retained CO2) which develops with hypoventilatory episodes. Depression, personality changes, and intellectual deterioration may also develop.

Almost all patients or their bed partners give a chronic history of heavy, loud snoring. The snoring is produced from the passage of air through the oropharynx causing vibrations of the soft palate. Typically the snoring is interrupted by periodic apneic episodes that may last 30 to 90 seconds. A loud snort followed by a hyperventilation usually signals an end to the apneic episode.

An in-lab sleep study or polysomnography takes as long as 8 hours of recording sleep. Although, 4 hours is generally thought to be enough data for interpretation. A home sleep test can be performed in the comfort of your bed using our low profile HST device.

The profound effects of sleep apnea upon the cardiovascular, respiratory systems and neuro-cognitive function have been documented. The Sleep Heart Health Study and the Wisconsin Sleep Cohort3,4 have demonstrated a strong association between SDB and hypertension. Patients with an apnea-hypopnea index (AHI) > 15 have a 2.89 fold greater chance of developing hypertension.5 In patients with an AHI > 11, 2.38 relative risk for congestive heart failure and a 1.58 risk for cerebrovascular disease exists.

Patients with OSA most often complain of excessive daytime sleepiness (EDS). The patients may experience serious social, economic, and emotional problems from the EDS associated with this syndrome. The uncontrollable desire to sleep may predispose the patients to safety sensitive occupational or automobile accidents.

There are several medical treatment options for OSA including weight loss, improved sleep hygiene, oral appliance and CPAP/BiPAP. The two most applied treatment modalities will be reviewed, weight loss and CPAP.


Weight loss decreases comorbid risks and is beneficial in combination with other treatment modalities. In a longitudinal study of moderate weight gain, Pepperd et al found that a 10% weight gain predicted a 32% increase in AHI while a 10% weight loss predicted a 26% decrease in AHI. Stategies for weight loss include combined dietary, exercise, and behavior therapy.


CPAP, a non-invasive methodology, is currently the mainstay of medical management of OSAS. CPAP has been showned to improve ambulatory blood pressure and has reduced the cardiovascular risk in men with OSA with an AHI >30. In addition, CPAP appears to be protective. CPAP has been shown to improve measures of SDB including apnea, AHI, RDI. It has been shown to improve insulin sensitivity, and reduce the risk of automobile accidents. CPAP is covered by Medicare if AHI >15 or AHI > 5 with EDS, impaired cognition, hypertension, or history of ischemic heart disease or stroke. If tolerated, CPAP or BiPAP offers the best form of treatment, but doesn’t offer a chance for cure. In addition, one night off CPAP reverses all the gains derived from sleeping with the device12.

A contemporary two-phase surgical approach for OSAS treatment has been developed to limit over operating and to decrease risks of surgery. It is important to note that if this phased protocol is used the patient and referring physician must understand that both phases may be necessary. The protocol was not intended to be a single phase protocol. A polysomnogram is necessary after phase one (4-6 months). If the patient is controlled no further treatment is needed. If incompletely treated then phase two is appropriate.


The first phase is the most conservative approach and addresses palatal and tongue base obstruction without movement of the jaw or teeth. An Inspire hypoglossal stimulator may be considered for treatment of airway obstruction. It should be emphasized that improved surgical success is dependent upon optimizing the soft-tissue. Maxillomandibular advancement and Distraction Osteogenesis with Maxillary Expansion (DOME) are performed to improve severe obstructive sleep apnea as well as expand the nasal airway.


Combined advancement of the maxilla and mandible is the most recent and efficacious surgical procedure for the treatment of obstructive sleep apnea. The surgical technique includes a standard Le Fort I osteotomy in combination with a mandibular sagittal split osteotomy. A concomitant GA as previously described, is an adjunct and recommended to improve tongue advancement. MMA surgery may result in some facial change, which is most often favorable.


A DOME procedure may be performed in coordination with your Orthodontist to expand the upper jaw, correct dental occlusion problems, and improve nasal airflow.

Call to Schedule Your Sleep Apnea Surgery with Dr. Barrera or Dr. Bothwell Today

If you snore and feel constantly tired, find the help to put your life on a new, more energized path, possibly even without CPAP. Call 210-468-5426 with your questions. Dr. Barrera and Dr. Bothwell at the Endormir Sleep and Sinus Institute offer sleep apnea solutions for both children and adults in San Antonio, Texas.