Sleep apnea surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Surgery, usually the second line of treatment, is usually very effective in treating snoring. It could either be an inpatient or an outpatient procedure. Several surgical options exist depending on the site of the obstruction in the airway.

Surgery

Several surgical procedures (sleep surgery) are used to treat sleep apnea, although they are normally a second line of treatment for those who reject CPAP treatment or are not helped by it. Surgical treatment for obstructive sleep apnea needs to be individualized in order to address all anatomical areas of obstruction. Often, correction of the nasal passages needs to be performed in addition to correction of the oropharynx passage. Septoplasty and turbinate surgery may improve the nasal airway. Tonsillectomy and uvulopalatopharyngoplasty (UPPP or UP3) are available to address pharyngeal obstruction. Base-of-tongue advancement by means of advancing the genial tubercle of the mandible may help with the lower pharynx. Many other treatments are available, including hyoid bone myotomy and suspension and various radiofrequency

File:Cautérisation des parties molles - apnée du sommeil.svg

Illustration of surgery on the mouth and throat.

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Uvulopalatopharyngoplasty. This demonstrates the appearance after a tonsillectomy, followed by trimming of the uvula and folding it and suturing it to the palate.

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Maxillomandibular advancement with hardware. Note that the upper and lower jaws are moved as a unit, so that dental occlusion is maintained.

Other surgery options may attempt to shrink or stiffen excess tissue in the mouth or throat; procedures done at either a doctor's office or a hospital. Small shots or other treatments, sometimes in a series, are used for shrinkage, while the insertion of a small piece of stiff plastic is used in the case of surgery whose goal is to stiffen tissues.

The Pillar Procedure is a minimally invasive treatment for snoring and obstructive sleep apnea. This procedure was FDA indicated in 2004. During this procedure, three to six or more Dacron (the material used in permanent sutures) strips are inserted into the soft palate, using a modified syringe and local anesthetic. While the procedure was initially approved for the insertion of three "pillars" into the soft palate, it was found that there was a significant dosage response to more pillars, with appropriate candidates. After this brief and virtually painless outpatient operation, which usually lasts no more than 30 minutes, the soft palate is more rigid and snoring and sleep apnea can be reduced. This procedure addresses one of the most common causes of snoring and sleep apnea — vibration or collapse of the soft palate (the soft part of the roof of the mouth). If there are other factors contributing to snoring or sleep apnea, such as the nasal airway or an enlarged tongue, it will likely need to be combined with other treatments to be more effective.

The Stanford Center for Excellence in Sleep Disorders Medicine achieved a 95% cure rate of sleep apnea patients by surgery. Maxillomandibular advancement (MMA) is considered the most effective surgery for sleep apnea patients, because it increases the posterior airway space (PAS). The main benefit of the operation is that the oxygen saturation in the arterial blood increases. In a study published in 2008, 93.3.% of surgery patients achieved an adequate quality of life based on the Functional Outcomes of Sleep Questionnaire (FOSQ). Surgery led to a significant increase in general productivity, social outcome, activity level, vigilance, intimacy, and intercourse. Overall risks of MMA surgery are low: The Stanford University Sleep Disorders Center found 4 failures in a series of 177 patients, or about one out of 44 patients. However, health professionals are often unsure as to who should be referred for surgery and when to do so: some factors in referral may include failed use of CPAP or device use; anatomy which favors rather than impeding surgery; or significant craniofacial abnormalities which hinder device use. Maxillomandibular advancement surgery is often combined with Genioglossus Advancement, as both are skeletal surgeries for sleep apnea.

Several inpatient and outpatient procedures use sedation. Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing or collapses in a patient’s airways. Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided.

Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction, swelling may negate some of the effects in the immediate postoperative period. Once the swelling resolves and the palate becomes tightened by postoperative scarring, however, the full benefit of the surgery may be noticed.

A sleep apnea patient undergoing any medical treatment must make sure his or her doctor and anesthetist are informed about the sleep apnea. Alternative and emergency procedures may be necessary to maintain the airway of sleep apnea patients. If an individual suspects he or she may have sleep apnea, communication with their doctor about possible preprocedure screening may be in order.