So far in this series on obstructive sleep apnea (OSA), we have talked about what OSA is, how it is diagnosed, and potential nonsurgical treatments. This post will concern surgical procedures that can be used to treat or potentially cure OSA. All procedures discussed in this post are done in the operating room with the patient under general anesthesia. Office-based procedures will be discussed in the next (and final) post in the series.
From my training and experience for most of my career thus far, I’ve formed an overall bad impression of OSA surgery (though my view is starting to change because of the promising in-office procedures that will be discussed in the next post). My typical advice to patients has been that surgery is not the best option for treatment of OSA, with some exceptions.
The main exception is patients with one obvious anatomical problem that is causing their OSA (i.e. someone with huge obstructing tonsils but an otherwise wide-open upper airway). In these patients, you fix that one problem and the OSA is cured. Most patients are not so simple.
The downsides of surgery are several. First, most traditional surgeries for OSA have a very painful recovery, usually at least a week if not two weeks of severe throat pain during the healing period. Second, while most of these surgeries do improve the patient’s airway and improve their apnea-hypopnea index (AHI), they do not usually cure the patient (meaning a post-operative AHI of less than 5 and lowest oxygen level greater than 90%).
If a patient has a pre-operative AHI of 75 and I cut that in half with surgery (a huge improvement), he will still have an AHI of around 38 after the surgery which is still considered severe OSA and still requires CPAP treatment. You can probably see why most patients are reluctant to have an invasive and painful surgery if it won’t eliminate their need for CPAP. Although the numbers will be better, the patient’s situation won’t have changed all that much.
All that being said, let’s get into the different surgeries for OSA.
The most common surgery for OSA is called Uvulopalatopharyngoplasty, which is quite a mouthful (no pun intended). We ENT docs shorten that to UPPP (“U triple P”). In a UPPP, I remove the patient’s tonsils and uvula and then suture the tonsillar pillars to each other to widen the palate and throat.
UPPP was introduced in the late 1970s and early 80s and was initially thought to be a true cure for OSA. Unfortunately, more research has shown that while UPPP is effective in a subset of patients with obstruction mainly at the level of the tonsils and soft palate, it is usually not curative in most patients, especially those with obstruction lower down at the base of tongue (75% of OSA patients).
UPPP also has the downside of an extremely unpleasant and painful recovery. It is easily the most painful surgery for patients that I personally perform. For certain people, the pain is worth it, but I usually find myself talking patients out of doing a UPPP rather than encouraging them to have the procedure.
A somewhat less intense option to UPPP is simple tonsillectomy, which can help a lot in patients with very large tonsils but otherwise fairly open anatomy.
Other less common surgeries in the throat include genioglossus advancement and hyoid suspension. Genioglossus advancement uses a device called the Repose suture which pulls the tongue forward using a permanent suture attached to the inside bone of the chin.
Hyoid suspension involves using a suture to pull the hyoid bone in the throat (a small horseshoe shaped bone at the very back of the tongue and the top of the larynx) forward to give more room for air to pass.
I have some experience with the Repose suture and hyoid suspension as a resident but personally have found the results underwhelming.
More useful in my opinion are procedures that permanently shrink the base of tongue, including radiofrequency ablation in the office.
The final major category of surgeries for OSA which I perform are those which improve the passage of air through the nose. These include very common ENT procedures such as straightening a deviated nasal septum, reducing the size of the inferior turbinates, and adding support to a collapsing nasal valve (area just inside the nostrils). The nasal procedures generally have a less painful recovery than the throat surgeries discussed above.
Probably the “biggest” surgery for OSA is actually performed by an oral surgeon and is called maxillomandibular advancement. In this surgery, the bones of the upper and lower jaws are cut and moved forward to open more room in the airway. This surgery can actually work very well but is a difficult procedure and a hard recovery.
The take-home message about traditional sleep apnea surgery is as follows. Sleep surgery usually improves the patient’s “numbers” like the AHI, but frequently does not change the patient’s day-to-day life. I.e. most patients will be on CPAP before surgery and will continue to need CPAP after surgery, though maybe at a lower setting. Because of the fairly painful recovery for most of these surgeries, most ENT doctors including myself have a hard time recommending them. The risk and associated post-surgical pain outweigh the likely benefit most of the time.
What most of us docs have been searching for is an office-based procedure with an easier recovery that still provides reasonably good results. I’m optimistic that we have found such an option, and I will tell you all about it next time!
Click HERE for the next (and final) post in the series.