John Holcomb, M.D. - Wake Up Call
Dr. John Holcomb’s medical career was inevitable: his mother has a photo of him when he was five, wearing a stethoscope and checking on his younger brother. There was nothing in those early years to suggest that he would one day be on the other side of the stethoscope, undergoing a major surgical procedure to resolve severe obstructive sleep apnea.
A United States Army surgeon for 23 years, with service in Somalia during the Black Hawk Down incident, Dr. Holcomb joined the faculty of McGovern Medical School at UTHealth as a professor in 2008. A year earlier, he had undergone a sleep study at Brooke Army Medical Center, Fort Sam Houston, in San Antonio, Texas, and was diagnosed with severe obstructive sleep apnea (OSA). He was placed on CPAP – continuous positive airway pressure therapy, which uses a machine to increase air pressure in the throat during sleep to keep the airway open.
“CPAP is the most effective treatment for obstructive sleep apnea for most people, assuming the patient uses it long enough during the night to produce the ideal therapeutic effect,” says James Wilson, D.D.S., professor and vice chair of the department of Oral and Maxillofacial Surgery at McGovern Medical School. “But many people fail to use the device every night or take off the mask during the night because they find it uncomfortable.”
Dr. Holcomb was one of those people. “I wore the CPAP about three hours a night and didn’t take it with me when I traveled because it was bulky,” he says. “So, of course, I had the recurrent symptom of daytime sleepiness.”
Things came to a head in 2012 when he was returning from a SCUBA certification dive with his son Ian, who was 12 at the time. “I was driving down the highway and fell asleep at the wheel at around 2 or 3 in the afternoon,” says Dr. Holcomb, an accomplished trauma surgeon affiliated with the Texas Trauma Institute at Memorial Hermann-Texas Medical Center. “I veered to the left and hit the concrete barriers. The damage to the car was minimal, but I was shaken by the fact that I had endangered my son’s life. My wife and I conferred and decided it was time for a definitive procedure. I did a fair amount of research online and in the medical literature, and talked to people about the various surgeries available. Eventually, I decided on the procedure with the highest success rate.”
Maxillomandibular advancement (MMA), a surgical procedure that moves the upper jaw (maxilla) and lower jaw (mandible) forward to enlarge the airway, has the highest proven effectiveness of any surgical procedure for severe OSA. Performed cosmetically for decades to correct deformities of the face, including a smaller-than-normal mandible and misalignment of the teeth, the surgery takes three to four hours and requires a two- to three-day hospitalization. Patients can expect to be fully recovered in about four weeks.
“I saw John for about a year before he finally decided to have the surgery,” Dr. Wilson says. “That’s not an uncommon decision-making pathway. As a surgeon, he had a good understanding of what would be done during the procedure. He was honest with himself about his use of CPAP, and he also knew that obstructive sleep apnea carries a significant risk for heart disease, stroke, diabetes and neurocognitive problems. He was aware that fragmentation of sleep patterns affects the ability to work and shapes emotional behaviors and relationships. Each of these risks has the potential to change your life.”
In the summer of 2013, Dr. Holcomb had another sleep study done, this time by Richard J. Castriotta, M.D., FCCP, FAASM, professor and division director of pulmonary and sleep medicine in the department of Internal Medicine at McGovern Medical School. Dr. Castriotta is board certified in internal medicine, pulmonary disease and sleep medicine.
“John had severe obstructive sleep apnea and by severe, I mean he stopped breathing completely or partially almost 50 times an hour,” Dr. Castriotta says. “His oxygen saturation went down dramatically, putting him at high risk for developing cardiovascular disease. Like anyone with sleep deprivation, he faced the potential for a lot of adverse consequences – declining cognitive function among them. He had had one automobile accident. There’s a high rate of repetitive accidents among untreated sleep apnea patients. Ironically, his sleep apnea was completely resolved by CPAP, which remains the most effective recognized overall treatment for most people if they can tolerate it. Some people love CPAP. Others, like John, hate the inconvenience.”
Dr. Holcomb scheduled his surgery for November 2013. To prepare for the procedure, Dr. Wilson used a new technology that’s fast becoming the standard of care at academic medical centers like Memorial Hermann-TMC. “We use a software program to create a 3-D model that allows us to plan the surgery in advance,” Dr. Wilson says. “In the old days we used models on an articulator and moved them around. Having the ability to accurately simulate the movement of the jaw allows us to tweak the relationships of the structures and make splints to be used during surgery. The technology is so precise that the patient has an advance view of the changes that will occur in facial structure, which creates more confidence in the outcome. Being able to show patients what they will look like after surgery is so much better than saying ‘Trust me.’”
As a surgeon, Dr. Holcomb was impressed with the pre-surgical planning process. “Preoperative planning was very meticulous, with measurements, photos, x-rays and CT scans,” he says. “They explained the procedure in great depth, and I felt very well prepared.”
Dr. Wilson admits that maxillomandibular advancement is a significant surgery. “But the result in at least 90 percent or more of patients is either very successful or a total cure for obstructive sleep apnea. The medical literature shows that positive results are maintained long term. People are happy because they no longer have the portability issues of CPAP when traveling and the paraphernalia issues at home. That’s freedom.”
“It is a big operation,” Dr. Holcomb says. “The flip side is I no longer snore, my wife is happy, and I wake up refreshed. My energy level is much better. All of a sudden you’re getting REM sleep and dreaming again.”
There are degrees of obstructive sleep apnea, and most people can be treated effectively with a nonsurgical procedure. “For people who are willing to do it, maxillomandibular advancement surgery offers an alternative to CPAP,” Dr. Wilson says. “You fix the disorder by pulling the jaw forward and changing the anatomy. It’s a permanent effect.”
Dr. Wilson and Dr. Castriotta are lead physicians in a pilot study under way at Memorial Hermann-TMC and McGovern Medical School: a prospective study of maxillomandibular advancement surgery compared to CPAP for the treatment of moderate to severe OSA. The study is funded by the Oral & Maxillofacial Surgery Foundation.
“Our hypothesis is that MMA may provide comparable effectiveness to CPAP in some individuals,” Dr. Castriotta says. “We’ll perform sleep studies on subjects before and after MMA surgery as well as before and during CPAP treatment. Dr. Holcomb’s case is a very nice example of why we are so enthusiastic about this surgical approach to the treatment of OSA and the newly funded research study.”