Sleep apnea surgery can help people when other treatments can't. Sleep apnea treatments typically begin with the least intrusive approach as well as a consultation with a physician or sleep specialist. If less invasive approaches don't work, surgery may be the next step. Surgical procedures generally address specific problems that cause the apnea and are chosen according to the patient's needs.
Types of Sleep Apnea Surgeries
For some patients, structural problems in the mouth or throat interfere with the ability to breathe while sleeping. These procedures can help.
UPPP Procedure
The uvulopalatopharyngoplasty (UPPP procedure) is a popular choice for dealing with obstructive sleep apnea (OSA). This approach addresses structural problems in the throat and the roof of the mouth. Removing excess tissue from this region opens the airway passage while preventing a collapse of tissue in the throat that can lead to obstructed breathing.
UPPP removes excess tissue in the soft palate in the back of the mouth. Some surgeons choose to shorten the uvula while others completely remove this portion; it depends on the specific case. The adenoids and tonsils are also commonly removed during this procedure. This procedure can be completed during one surgery, or it can be scheduled as a step-by-step plan.
Risks of this procedure include pain, bleeding, possible infection, change in voice tone, and difficulty using CPAP in the future.
LAUP Procedure
Surgeons may also use a laser to remove tissue; in these cases, the procedure is called laser-assisted uvula palatoplasty (LAUP). This surgery treats snoring using local anesthesia in an outpatient procedure. It is not recommended for use in the treatment of OSA, but some surgeons do use it in this way for patients. The procedure uses lasers to remove obstructive tissue in the back of the throat and the soft palate. LAUP is not always completed in one session but may also need to be staged as well.
Risks of this procedure include throat dryness, throat narrowing and scarring. Both UPPP and LAUP are about 50-65% effective for treating OSA; LAUP may be somewhat more successful for treating mild snoring.
Adenotonsillectomy
Enlarged tonsils and adenoids may cause obstruction of the airways and sleep apnea; this is often the main cause of sleep apnea in children and adolescents. This procedure can be used for both adults and children, but it generally is not curative for adults. The recovery time from this surgery is usually harder for adults. Risks include bleeding and infection.
Palatal Implants
Palatal implants are used to treat snoring or mild sleep apnea. These implants are placed in the soft palate under local anesthesia; the goal is that the palate will scar and become less likely to fall back and obstruct the throat during sleep. It may take several months for the implants to work. Discomfort associated with this procedure, which is referred to as the pillar procedure, is minimal; complications with this procedure are few as well.
Structural Surgeries
Sleep apnea may also be caused by abnormalities in the nose, excess tissue in the tongue, or problems with the jaw. These surgeries can repair structural problems.
Nasal Polypectomy
The nasal polypectomy procedure removes polyps (small growths in the nasal passage). In some people, the polyps may cause nasal obstruction, which may lead to OSA. This surgery may done endoscopically through the nostrils so that there will be little external scarring. Risks include bleeding, infection, and scar formation inside of the nose.
Nasal Septoplasty
During a nasal septoplasty, the surgeon repairs malformations in the nasal passage. A patient with a deviated septum that is causing obstruction could benefit from this approach. This surgery can be performed as a day procedure and generally does not leave scarring. Risks of the procedure include bleeding, infection, pain, and nasal congestion after surgery.
Glossectomy
Glossectomy surgery involves removing part of the tongue as well as some excess tissue in the throat. If the OSA is caused by excess tongue tissue, the patient may benefit from this procedure. A glossectomy can be up to 70% effective. Risks associated with this procedure, while uncommon, include bleeding, infection, numbness of the tongue, and difficulty moving the tongue.
Tongue Suspension
Tongue suspension is a relatively new approach that uses a screw or sutures attached to the tongue with surgical thread to keep the airway passage open. This procedure may also help if the tongue is the cause of the obstruction. This type of surgery is a minimally-invasive procedure without many known long-term complications at this time.
Hyoid Advancement Surgery
In this surgery, the hyoid bone under the chin is moved forward; this in turn moves the base of the tongue and the epiglottis forward. More space is opened up at the back of the throat. This can be performed as a day procedure and may be helpful in people whose tongue is the cause of the obstruction. Swallowing may be affected for around one week after this surgery.
Maxillomandibular Advancement
Maxillomandibular advancement is reserved for life-threatening cases in which other approaches have not been successful. Patients with moderate to severe OSA, significant jaw problems, or morbid obesity may have some success with this procedure. By moving the upper and lower jaw forward, more space is opened up in the back of the throat. Complications can include bleeding, infection, misaligned bite, and altered sensation of lip and mouth. This procedure can be up to 98% effective.
Other Types of Surgeries
Tracheostomy
A tracheostomy completely bypasses the obstructed airway by creating an opening in the throat. A tracheostomy tube is placed in the lower neck, directly in the passage connecting the voice box to the lungs. Physicians use this approach for people who are not candidates for other interventions, particularly morbidly obese patients.
This surgery is almost always successful in treating OSA. Risks include scarring, bleeding, infection, difficulty speaking, and a higher risk of lung infections.
Weight Loss Surgery for OSA
Bariatric surgery is a procedure that helps people to lose weight. In some cases, individuals with sleep apnea can overcome the sleep problem by getting rid of excess fat in the neck and throat region. While this approach is not intended to treat the sleep condition, relief from sleep apnea can be a pleasant side effect of the surgical procedure over time. The success of this procedure at improving sleep apnea varies, with some studies showing high-resolution rates and others showing less success.
Risks include bleeding, infection, blood clots, problems with your GI system, and death.
Making the Decision
Surgery vs. CPAP
For many patients, CPAP machines do work. CPAP can be up to 95% effective in treating OSA; however, due to noncompliance and challenges using the machine, only 40% of people use the CPAP correctly. If you are unable to use the machine correctly, it may be time to move to surgery.
Discuss Your Options with Your Doctors
Your primary care physician may be the first doctor that you speak to about having a surgical procedure; however, he or she is unlikely to be the one to perform the surgery. Your physician may recommend an ear, nose and throat specialist who can determine if there are any structural problems leading to the apnea and which surgery may be best for you.
Although you may have already seen a specialist when you were first diagnosed with sleep apnea, you may need to see a sleep disorder specialist again before undergoing a surgical procedure for the sleep disorder. A sleep study may also be necessary to determine the best approach for your specific condition.
Anesthesia
As you ask questions about your potential surgery, you should find out about your anesthesia options. In an article, Anesthesia Safety Always an Issue with Obstructive Sleep Apnea, Okoronkwo U. Ogan, M.D.and David J. Plevak, M.D. discuss the complications of using anesthesia on patients who have this sleep disorder. Anesthesia curtails the muscle activity in the airway passage which may be a problem in people with OSA. It is extremely important to have proper monitoring after using anesthesia, whether you have a same day procedure or not.
Having sleep apnea may influence the anesthesiologists' choices for your care as well. If possible, local or regional anesthesia may be a better choice for some patients with more serious apnea.
Moving Forward
Some clinicians recommend that you get a second opinion if a doctor suggests surgery for sleep apnea because of the possible risks of surgical procedures. Understanding the different types of surgery and which one may be best for you allows you to ask appropriate questions of your doctor and any other physician you might be referred to. If you make the decision to have surgery for OSA, make sure you investigate your options so you can make the best decision possible.
