Optimal treatment of obstructive sleep apnea requires close collaboration among multiple medical specialties because no single treatment has proven effective for all patients.
Continuous positive airway pressure therapy has low risks and high efficacy, which makes it a first-line option for moderate to severe obstructive sleep apnea. However, not all patients can tolerate positive airway pressure. An otolaryngologist – head and neck surgeons and oral and maxillofacial surgeons – can play an important role in the care of patients with airway abnormalities who are struggling with their CPAP.
Over the past 10 to 15 years, a number of surgical procedures have been developed or used in new ways to improve outcomes for OSA patients. Their use remains controversial due to the wide variety of surgical options, variable reported success rates, limited data on long-term outcomes, and potential complications.
Evaluating surgical candidates
Airway evaluation is crucial in helping to decide which patients are likely to benefit from a particular surgical procedure. Although surgical treatment of OSA is based on a number of factors, it ultimately targets the areas responsible for the narrowing or complete obstruction of the airway. Airway blockage can occur in three major areas: the nose, palate, and tongue (also hypopharyngeal or retroglossal) regions. In an individual patient, often more than one area causes OSA. These areas can be approached during the same or different surgical procedures. The aim is to enlarge and stabilize the airway to eliminate this narrowing or collapse.
Evaluation by an otolaryngologist helps to determine whether the patient has a predominantly a fixed skeletal obstruction or a soft tissue obstruction potentially modifiable without surgery. Marked septal deviation or turbinate hypertrophy usually requires surgery for resolution. Alar collapse may be adequately treated by internal or external dilators, although surgery is sometimes required for repair of marked alar collapse.
In addition to the clinical upper airway examination, important technological advances can aid in evaluation of surgical candidates.1-3 Flexible fiberoptic nasopharyngoscopy facilitates direct upper airway examination. It can help determine if hypertrophied tonsillar and adenoid tissues are contributing to airway obstruction. Obstruction may be reproduced using nasopharyngoscopy with the Mueller maneuver (the patient takes deep breath with the mouth closed and the nose pinched). Lateral cephalometric X-ray helps identify facial skeletal and soft tissue structures and the posterior airway space at the oropharynx.4
Patient evaluation remains an area of active research within the surgical community. The patient’s airway anatomy, medical status, OSA severity, and personal preferences all play a role in selection of surgical procedure. Our major goal is to determine which procedure or combination of procedures offer the best tradeoff between risks and benefits for a patient.5,6 Following is a brief review of the surgical options performed most frequently for patients with OSA.
Relief of nasal obstruction
Medical and surgical treatment of the nose rarely alleviates OSA by itself, but it can play a major role in making CPAP more comfortable for patients and in improving their adherence to the therapy. Nasal CPAP is difficult if the nasal airway is narrowed.
Treatment of nasal symptoms is based on accurate diagnosis and monitoring of the response to interventions. Medical treatments include salt water or medication sprays and oral medications such as topical steroids or antihistamines, oral antihistamines, or decongestants.
Surgical treatments have an even broader range and complexity. The goal is to reduce nasal resistance. These procedures include septoplasty, septorhinoplasty, and turbinate reduction.
Soft palate surgery
For many years, the mainstay of surgical treatment of OSA was soft palate surgery, typically uvulopalatopharyngoplasty (UPPP), with or without tonsillectomy. The intent is to enlarge the airway by removing or shortening the uvula as well as part of the soft palate.
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Accumulated experience showed that this procedure worked well if patients had airway obstruction only at the level of the palate. It did not work very well if patients had other areas of blockage such as the tongue region.7
Subgroups of patients can achieve successful outcomes (defined below) as much as 80 percent of the time after palate surgery alone, but many patients will benefit from palate surgery in combination with procedures to treat other regions of the airway, as needed.2
Potential complications include minor bleeding and less often nasal regurgitation, velopharyngeal incompetence, hypernasal speech, palatal stensosis and residual OSA.4
Tongue region procedures
Several tongue region procedures have been developed over the past 10 to15 years, including genioglossus advancement, tongue radiofrequency, midline glossectomy, hyoid suspension, and tongue stabilization. Each of these function through different mechanisms, but they all treat this region by enlarging and/or stabilizing this section of the airway. Multiple studies show that these procedures improve outcomes in patients who would not benefit from palate surgery and tonsillectomy alone.8 Bleeding, dysphagia, painful swallowing, and airway edema are possible complications associated with tongue region procedures that may persist for two to three weeks, but in certain cases may be permanent.
Maxillofacial procedures
Maxillofacial procedures such as maxillomandibular or bimaxillary advancement enlarge and stabilize the airway at both the palate and tongue regions. Compared to other single procedures, they offer the greatest benefits for most patients.
However, the tradeoff is a longer recovery period and, in most cases, somewhat greater risks. The chances of obtaining a successful surgical outcome varies depending on many factors, and the limited available evidence suggests that patients who have previously undergone some of the procedures outlined above may experience better results than those with maxillomandibular advancement as a first-stage procedure.9,10
Measuring success
The traditional metric of surgical outcomes has been comparison of the preoperative and six-month postoperative sleep studies because these quantify the severity of OSA. The most common criteria for defining a successful surgical outcome involves a reduction of at least 50 percent in the severity of OSA (with no worse than mild residual disease) and a normalization of oxygenation.7
Many factors are associated with surgical outcomes, and it is difficult to make sweeping generalizations about the chances of obtaining this successful result. Approximately 50 percent to 80 percent of patients can achieve success after surgical treatment tailored to their anatomy, although certain groups of patients may have a higher or lower likelihood.2,9
That being said, although surgical treatment often does meet this bar, the use of these criteria may be an oversimplification. While the goal of surgical treatment always should be to alleviate all OSA (have a completely normal postoperative sleep study), the true goals of OSA treatment include alleviation of the disorder’s health impacts, whether cardiovascular, pulmonary, or metabolic; decrements in quality of life related to sleep disruption; and, to a lesser extent, disruptive snoring sounds that can be troublesome for anyone within earshot.
Strong evidence exists to suggest that patients may realize benefits after surgical treatment even if they do not achieve so-called successful surgical results as defined by the sleep study. Several high-quality studies – considering mortality rates, cardiovascular disease, and quality of life – demonstrate that patients with moderate to severe OSA undergoing surgery do better than untreated patients, such as those unable to tolerate CPAP therapy and those who may not attain ideal results with other modalities.11-13
Surgery and CPAP compliance
Some patients who undergo surgery for OSA will continue to require CPAP to treat unresolved symptoms. However, few studies have considered the effect of surgery on CPAP use. Most research reporting on patients who had nasal airway obstructions corrected showed that these procedures may contribute to a decrease in CPAP level and tolerability postoperatively.
Some researchers have suggested that UPPP, when performed alone, could compromise patients’ ability to use CPAP because it allows for oral air leak. A small retrospective pilot study reported in September challenges those findings.14 Clinically significant oral leak was not documented for eight patients who underwent UPPP in combination with either tonsillectomy, septoplasty or both. The study concluded that in appropriately selected patients, upper airway surgery may improve CPAP compliance in patients with OSA.
More conclusive data on whether surgical interventions have a beneficial effect on CPAP compliance is needed.
Setting clear goals
Surgery for OSA does not eliminate all disordered breathing events forever in all patients. In general, these procedures are not a permanent cure, and data on long-term efficacy is lacking.
Therefore, choices regarding surgical treatment should be based on a consideration of benefits and risks. While some OSA patients achieve meaningful benefits, they may face an increased risk of complications after all procedures, not just those designed specifically to treat this disorder. However, the risk of serious complications occurring during surgery and the immediate recovery period is between 1 percent to 2 percent, and patients who have serious or unstable medical illness are at greatest risk of these complications.15,16
Patients who are considering surgery for OSA should discuss all treatment options, their rationale, and goals with a sleep specialist and an experienced surgeon. Patients must be aware they may have to undergo more than one surgery to eliminate their apneas sufficiently. In some cases, the emphasis of surgical intervention is not on a cure, but to improve patients’ chances of using CPAP successfully.
References
1. Chandrashekariah R, Shaman Z, Auckley D. Impact of upper airway surgery on CPAP compliance in difficult-to-manage obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2008;134:926-30.
2. Doghramji K, Jabourian ZH, Pilla M, Farole A, Lindholm RN. Predictors of outcome for uvulopalatopharyngoplasty. Laryngoscope. 1995;105:311-4.
3. Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg. 2002;127:13-21.
4. Ritter CT, Trudo FJ, Goldberg AN, Welch KC, Maislin G, Schwab RJ. Quantitative evaluation of the upper airway during nasopharyngoscopy with the Mller maneuver. Laryngoscope. 1999;109:954-63.
5. Mehra P, Wolford L. Surgical management of obstructive sleep apnea. BUMC Proceedings. 2000;13:338-42.
6. Faber CE, Grymer L. Available techniques for objective assessment of upper airway narrowing in snoring and sleep apnea. Sleep Breath. 2003;7:77-86.
7. Kezirian EJ. Drug-induced sleep endoscopy. Op Tech Otolaryngol 2006;17:230-2.
8. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;19:156-77.
9. Kezirian EJ, Goldberg AN. Hypopharyngeal surgery in obstructive sleep apnea: an evidence-based medicine review. Arch Otolaryngol Head Neck Surg. 2006;132:206-13.
10. Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993;108:117-25.
11. Li KK, Riley RW, Powell NB, Guilleminault C. Maxillomandibular advancement for persistent obstructive sleep apnea after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope. 2000;110:1684-8.
12. Weaver EM, Maynard C, Yueh B. Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery. Otolaryngol Head Neck Surg 2004;130:659-65.
13. Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J. Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up. Am J Respir Crit Care Med 2002;166:159-65.
14. Woodson BT, Steward DL, Weaver EM, Javaheri S. A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 2003;128:848-61.
15. Kezirian EJ, Weaver EM, Yueh B, Deyo RA, Khuri SF, Daley J, et al. Incidence of serious complications after uvulopalatopharyngoplasty. Laryngoscope. 2004;114:450-3.
16. Kezirian EJ, Weaver EM, Yueh B, Khuri SF, Daley J, Henderson WG. Risk factors for serious complication after uvulopalatopharyngoplasty. Arch Otolaryngol Head Neck Surg. 2006;132:1091-8.
Eric J. Kezirian, MD, MPH, is director of the division of sleep surgery in the department of otolaryngology – head and neck surgery at the University of California, San Francisco. He receives research support from the National Institutes of Health and the Triological Society. He can be reached through the the website: sleepsurgery.ucsf.edu
