International Surgical Sleep Society

Surgery for Obstructive Sleep Apnea

Am I a Candidate?

In order to be a candidate, you should have tried positive airway pressure (PAP) as this is the first-line treatment for OSA (your physician would decide this). If you are not able to consistently use PAP therapy, your physician can look at other treatment options, including oral appliance and surgery.

What are the Surgical Options?

Upper airway surgery to directly treat OSA is not “one size fits all”. There are numerous types of throat surgery for OSA, and it is critical to choose the procedure that corrects the individual’s source(s) of obstruction.

Studies have shown that determining the location of the obstruction site can significantly increase success rates. Generally speaking, there are 2 main sources of obstruction: the soft palate and the tongue (Figure 1). In each patient, the surgeon will attempt to identify whether there exists a single site of obstruction or a multilevel obstruction. This identification is done with a fiber-optic endoscope examination performed through one of the nostrils. The exam can be done in the clinic with the patient awake or with the patient under sedation in the endoscopy suite or operating room. The sedated exam is called drug-induced sleep endoscopy (DISE) and is intended to recreate natural sleep.

image001
Figure 1:  “X” marks obstruction behind the soft palate;
“O” marks obstruction behind the tongue base

There are 4 different classes of surgery to improve blockage in the throat:

chart

Each of these surgery classes can address both soft palate and tongue-based obstruction. Choosing amongst the 4 options requires consideration of each patient’s OSA severity, throat anatomy, body weight, medical problems and personal preference.

Of note, it may take more than 1 procedure to satisfactorily address OSA; thus, the above surgery classes may be performed in a staged manner.

A. Soft tissue surgery

Soft tissue surgeries involved direct manipulation of the soft palate and tongue musculature. The most common type of soft tissue surgery for OSA is uvulopalatopharyngoplasty (UPPP). A modified version of UPPP, known as expansion sphincter pharyngoplasty, has become increasingly popular (this procedure is particularly effective in patients with lateral pharyngeal wall obstruction).

If the physician/surgeon finds that there are more than one anatomical site that is obstructing, the surgeon might recommend multilevel surgery for the OSA patient (e.g. nose, palate and/or tongue surgery).
List of available soft tissue surgeries:

Nose

  • Septoplasty
  • Submucous Resection
  • Turbinate Reduction
  • Turbinoplasty
  • Turbinate Radiofrequency
  • Endoscopic Sinus Surgery
  • Adenoidectomy

Palate

  • Palatine Tonsillectomy
  • Anterior Palatoplasty
  • Expansion Sphincter Pharyngoplasty
  • Z-palatoplasty
  • Uvulo-Palatal Flap
  • UvuloPalatoPharyngoPlasty (UPPP)

Tongue

  • Lingual Tonsillectomy
  • Midline Glossectomy
  • Tongue Suspension

B. Skeletal Surgery

There exist several skeletal surgeries, each designed to address single obstruction (palate or tongue) or double-obstruction. Most commonly, maxillomandibular advancement (MMA), also known as double-jaw surgery is performed to treat double-obstruction. MMA has been shown to be effective in treating OSA. Given the significant recovery time, however, MMA is reserved for motivated patients with limited health problems.

Other skeletal surgeries:

Palate

  • TransPalatal Advancement Pharyngoplasty

Tongue or Hyoid Bone

  • Genioglossus Advancement Mandibulotomy
  • Hyoid suspension

C. Neurostimulatory Surgery

Nerve stimulation therapy represents the most recent advancement in sleep surgery. This therapy works by delivering electrical stimulation to the nerve which controls tongue movement (hypoglossal nerve). In essence, electrical stimulation of the tongue prevents falling back of the tongue and soft palate into the airway. Thus, this treatment is designed to treat double-obstruction.

Inspire® is a type of nerve stimulator which is synchronized to the respiratory cycle via a respiratory sensor lead. Currently, Inspire® is commercially available in both the United States and Europe. ImThera® is another nerve stimulator but does not include a respiratory sensing lead. It is commercially available in several European countries as well as Colombia.

D. Upper airway bypass surgery

Tracheostomy can be performed as a means of bypassing the upper airway. Tracheostomy is generally highly effective in treating OSA. The main drawbacks of the surgery are aesthetic concerns, maintenance of the stoma (neck opening) and lifestyle change (not able to participate in activities involving submersion in water such as swimming).

Raj C. Dedhia, MD MS, Director of Sleep Surgery, Emory University, Atlanta, GA (USA)