Surgery Options to Correct Anatomy for Sleep Apnea

Going Under the Knife to Treat Sleep Apnea When CPAP Fails

Surgery may be an effective treatment of sleep apnea is select individuals
Surgery may be an effective treatment of sleep apnea is select individuals. Getty Images

For those who are unable to tolerate continuous positive airway pressure (CPAP) to treat their obstructive sleep apnea (OSA), what surgery options exist? There are a handful of surgical treatments, but they may be of limited effectiveness and may not be for everyone. Review some of these options and whether they may be right for you.

Uvulopalatopharyngoplasty (UPPP)

This has historically been the most common surgical treatment in individuals with mild and moderate OSA who cannot tolerate CPAP or other medical management.

UPPP is the surgical removal of excess tissue in the upper airway, including the back of the mouth at the soft palate and along the throat.

UPPP involves the removal of tissue from the tonsils, uvula, and the soft and hard palate (the roof of the mouth). These tissues may be obstructing the airway, and it is hoped that removing them will clear this obstruction.

There are various complications that can occur with the procedure. As with any surgical procedure, there are risks of pain, bleeding, and infection. In addition, there may be changes in the voice, a narrowing of the pharynx (called stenosis), a sensation of a foreign body in the throat, or the risk of velopharyngeal insufficiency (regurgitation of food, liquids, or saliva into the nose when swallowing). There may also be difficulties tolerating CPAP if it is needed after the procedure.

Unfortunately, only 50% of adults treated with UPPP cut their number of apnea and hypopnea events by half or more.

These improvements may also diminish over time, especially with weight gain and aging. It is considered a second-line therapy, after CPAP treatment, and only for those who have tissue obstruction of their airway. Due to the pain and limited benefit, it has slowly fallen out of favor as a definitive solution.

Other surgeries involving the soft palate can also be performed, including the implantation of stabilizers called the pillar procedure.

Implantation of a Pacemaker for the Tongue Called the Inspire Nerve Stimulator

A newer treatment option that seems to be promising is the implantation of a pacemaker for the tongue called the Inspire nerve stimulator. It acts on the hypoglossal nerve and reduces the collapse of the airway by contracting the muscles of the tongue and upper airway. It is indicated in those who have failed CPAP therapy with the presence of moderate to severe sleep apnea (with a baseline AHI of 20 or higher). Sleep endoscopy is performed to evaluate who is likely to get a benefit.

Tracheostomy as a Last Resort Option

Tracheostomy is a surgical incision in the front of the windpipe (trachea), with placement of a plastic tube to keep this open, and it is highly effective in treating OSA. It bypasses the obstruction of the upper airway, which is the primary cause of the disorder.

This was the mainstay of treatment in severe sleep apnea before the invention of CPAP therapy in 1981. 

Due to its rather invasive nature, and the effectiveness of CPAP, it is rarely used any longer. It is generally reserved for those with life-threatening disorders such as cor pulmonale, arrhythmias, or severe hypoxemia (low blood oxygen levels) that cannot be controlled with other treatment.

Are There Other Surgical Options for the Tongue, Jaw, and Nose?

Depending on the cause of the apnea, genioglossus (tongue) advancement, hyoid (chinbone) myotomy with suspension, and maxillomandibular (jaw) advancement may be performed. All of these procedures correct anatomical defects related to the muscle and bones supporting the tongue and lower jaw, and they would not be performed in the absence of these defects. As the effectiveness varies, and the intensity of the procedure may be high, these surgeries are performed less often.

Nasal surgery may also be done to correct a deviated nasal septum, but this improvement in airflow through the nose may be insufficient to resolve sleep apnea.

If you are curious about surgical treatment options that might be helpful to improve sleep apnea, speak with your sleep specialist and consider referral to a surgeon for additional evaluation of the potential risks and benefits in your case.

Sources:

Cooper, D.H. et al. The Washington Manual of Medical Therapeutics. 32nd edition. Lippincott Williams & Wilkins. p. 260.

Sher, A.E. et al. "The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome" Sleep. 1996;19:156-177.

Li, K.K. et al. "Long-term results of maxillomandibular advancement surgery." Sleep and Breathing. 2000;4:137-139.

Continue Reading