eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Palatal & Maxillofacial Surgery
Snoring and Obstructive Sleep Apnea, Surgery: Treatment
Updated: Sep 25, 2009
Treatment
Medical Therapy
Various medications have improved, with limited success, the activity of the upper airway muscles during sleep.
The mainstay of nonsurgical treatment for snoring and obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP), which became readily available in 1981. The positive airway pressure acts as a pneumatic stent to resist airway collapse. CPAP is administered through a nasal mask, nasal prongs, or a mask that covers both the nose and mouth. This treatment requires that the patient comply with wearing a mask, which some consider uncomfortable, at night. Patients who frequently travel may consider carrying a machine as impractical, regardless of the unit’s compactness.
Oral appliances or mandible advancement devices alter the position of the tongue base and mandible, respectively, in an effort to relieve obstruction. A survey of 110 patients who were treated with an oral appliance in a hospital-based dental practice revealed a success rate of more than 50% at 18 months.11 In small children, a nasal trumpet often prevents airway collapse and OSA. These measures are considered temporary.
Behavioral: The mainstay of behavioral therapy is weight loss and repositioning of the body during sleep to reduce snoring and apneic episodes. Some cases of OSA resolve with weight loss alone; however, long-term success is debated because many patients regain the weight. In addition, weight loss has not been proven to significantly improve the RDI in patients with moderate-to-severe sleep apnea.
In a recent study, Lankford et al evaluated 15 patients who had lost an average of 44.5 kg after undergoing Roux-en-Y gastric bypass. The same patients were able to reduce the pressure used on their CPAP machines by 18% (11 cm before surgery to 9 cm after surgery). The clinical significance of this change is questionable.
Other: A brief Internet search reveals countless claims about products that reduce or eliminate snoring. Such merchandise includes antisnoring pillows, throat sprays, chin straps, and Breathe Right strips, among others.
Surgical Therapy
When surgical therapy is indicated, conservative procedures are attempted first. These procedures include uvulectomy, nasal reconstruction, adenotonsillectomy, and palatal implants. More aggressive operations include uvulopalatopharyngoplasty (UPPP or UP3) and genioglossal advancement with hyoid myotomy. Second-line treatments for OSA are more complex and include maxillary-mandibular advancement, bimaxillary advancement, palatal advancement and tongue-base surgery (midline glossectomy), and tracheostomy.
Uvulectomy
A patient with a large uvula who snores and has few or no symptoms of apnea may benefit from uvulectomy. The patient can be given local anesthesia, and uvulectomy can be performed as an office procedure by using cautery or a carbon dioxide laser. In 1993, laser-assisted uvulopalatoplasty was first described as a procedure for individuals with mild OSA who snore. The procedure consists of incising the inferior rim of the soft palate and uvula. The tonsils are not removed.
Pillar system
The Pillar procedure, or palatal implants, is a relatively new and minimally invasive modality used to treat people with habitual snoring and those with mild-to-moderate OSA. The Pillar procedure addresses the soft palate, which is one of the anatomic components of sleep apnea and snoring.
During the Pillar procedure, 3 tiny woven inserts are placed in the soft palate to help reduce the vibration that causes snoring and the ability of the soft palate to obstruct the airway. Once in place, the inserts add structural support to the soft palate. Over time, the body's natural tissue response to the inserts increases the structural integrity of the soft palate. This procedure can be performed in the office or in the operating room as an adjunctive procedure.
A study performed in Norway indicated that the procedure is relatively successful (70%) in terms of bed-partner satisfaction.12 The cure rate depends on the severity of the preoperative sleep apnea. In most cases, the author encourages patients to undergo an overnight sleep study to assess the severity of the sleep-disordered breathing. On October 31, 2006, Medicare recognized this procedure and will reimburse the hospital for the implant devices. To date, most private insurance companies do not pay for the device and no carrier, to the author's knowledge, pays the surgeon.
Nasal reconstruction
Relief of nasal obstruction alone rarely cures OSA; however, patient tolerance and response to nasal CPAP are often improved. Septoplasty, septorhinoplasty, and turbinate reduction may be indicated in patients who have a predisposed anatomy. Turbinates can be reduced in a number of different ways, including traditional total or partial turbinectomies, submucous resection, cryotherapy, laser vaporization, bipolar radiofrequency coblation, and radiofrequency ablation. The author, 18 months ago, began to perform the lateral crural-J flap and found this procedure to be useful in patients with external nasal valve collapse who have had trouble tolerating CPAP with the nasal pillows mask.
Adenotonsillectomy
Adenotonsillectomy is often performed in the pediatric population to correct loud snoring and restless sleep. OSA is the primary indication for tonsillectomy in the pediatric population. The tonsils and adenoids can be removed or reduced in a number of ways. The surgeon's preference, cost, and postoperative pain and complications dictate which methods are used in each institution, which are subject to change over time. The methods include use of standard cautery, snare, bipolar cautery, harmonic scalpel, coblation, temperature-controlled radiofrequency, or microdebrider-powered shavers. In children, palatal surgery is usually necessary only in cases of extreme obesity.
Palatal surgery
UPPP is the most common procedure for the treatment of OSA syndrome. This procedure, introduced by Fujita in 1981, consists of tonsillectomy, reorientation of the anterior and posterior tonsillar pillars, and excision of the uvula and posterior rim of the soft palate. For patients without tonsils and enlarged tongue bases, Friedman advocated a Z-palatoplasty.
Transpalatal advancement pharyngoplasty has also been described and includes the removal of a portion of the posterior hard palate and anterior suspension of the soft palate. This procedure has evolved because of the unpredictable success of UPPP but is not widely performed in the United States.
Genioglossal advancement
Genioglossal advancement involves performing a mandibular osteotomy with anterior repositioning of the genioglossus-attached segment of the mandible. This procedure results in anterior displacement of the tongue.
Thyrohyoid suspension
Friedman designed thyrohyoid suspension for patients with moderate-to-severe OSA without enlarged palatine tonsils or patients with a short (<40-mm) hyomental distance. This procedure involves making a horizontal incision in the midline of the neck and advancing the hyoid bone anteriorly and inferiorly to the thyroid cartilage. In essence, this procedure draws the base of the tongue forward, making it less likely to fall back against the posterior pharyngeal wall during sleep. In addition, the hyoid bone may be repositioned anteriorly with transection of the infrahyoid muscles and suspension to the mandible.
Maxillary-mandibular advancement
Maxillary-mandibular advancement is performed in an attempt to widen the airway while maintaining the existing occlusion or, optimally, to obtain class I occlusion. Outer-table cranial bone is obtained initially through a coronal incision. Arch bars are placed, and maxillary osteotomies are performed. The maxilla is advanced 8-12 mm. Mandibular osteometries are also performed, and the mandible is advanced to obtain optimal occlusion. Bone grafts are used at the osteotomy sites as needed. Intermaxillary fixation is necessary postoperatively. A wide variety of maxillomandibular advancement techniques have been described, all with the goal of advancing skeletal support for the tongue and pharynx.
Tongue-base surgery
Lingual tonsillectomy, lingualplasty, and laser midline glossectomy are moderately successful procedures designed to reduce the mass of the tongue base. Proper postoperative airway support requires a temporary tracheotomy.
Radiofrequency ablation
Temperature-controlled radiofrequency tissue ablation (TCRFTA) is performed by submucosally delivering low-power electrical energy with a needle electrode. This procedure has been proposed to improve airway patency with less morbidity than that of traditional surgical approaches for OSA. This technology has been used in the tongue base and in the soft palate, sometimes both in the same setting. This procedure can be performed in the clinic with local anesthesia. Multiple treatments may accomplish the desired result.
Tracheotomy
Permanent tracheotomy cures OSA and is indicated most often in patients with severe apnea that is associated with life-threatening cardiac arrhythmias. Other less frequent indications may include morbid obesity, obstruction with severe hypoxia, and disabling daytime somnolence. This is not commonly used today.
Postoperative Details
Elevating the patient's bed in the recovery room and having a bilevel positive airway pressure (Bi-PAP) or CPAP device readily available is useful.
Traditionally, patients who undergo UPPP have been kept at least overnight to allow airway observation and to ensure adequate oral intake. Most serious complications seem to occur within the first 2-3 hours after surgery, and many patients (who have not undergone multilevel airway surgery) can be safely discharged home with detailed instructions.13 Patients who are discharged the day of surgery are counseled by the author to sleep in a recliner for the first 2 nights and to try to use their CPAP device if possible. Ensuring that the patient lives relatively close to the hospital and has reliable transportation is crucial.
Follow-up
After surgical procedures, polysomnography is necessary to assess the outcome. Six months is a generally accepted interval.
Complications
Postobstructive pulmonary edema occasionally occurs after relief of clinically significant airway obstruction. This condition manifests as airway edema and respiratory distress, and it results from the dramatic alteration in pulmonary physiology that follows obstruction removal.
Complications from septoplasty include nasal bleeding, septal hematoma, injury to the skull base that results in altered sense of smell or cerebrospinal leak, and septal perforation. Nasal crusting and bleeding can occur after turbinoplasty, regardless of the method used to reduce their size. Rhinoplasty may leave the patient with an unappealing cosmetic result that may require further surgery.
The palatal Pillar system has been used for only the past few years. To date, complications include superficial mucosal ulcerations and dislodgement of the pillar implants. The complications rate seems to be about 3%, based on the studies currently available.
Minor bleeding is the only common complication of uvulopalatoplasty; uvulopalatopharyngoplasty (UPPP) may provoke more significant bleeding when the tonsils are removed. Airway obstruction, velopharyngeal insufficiency, and nasopharyngeal stenosis are less common complications of UPPP. Most advocate inpatient care in a closely monitored unit. The most common (10-12%) complication of transpalatal advancement pharyngoplasty is an oronasal fistula, which seems to be temporary in most cases.
Tongue-base surgery is sometimes associated with bleeding, dysphagia, odynophagia, and airway edema. Superficial ulcer formation, hypoglossal nerve injury, and abscess are less common complications. Taste may also be altered after tongue-base surgery and, in rare cases, standard tonsillectomy.
Radiofrequency ablation of the tongue base and soft palate is associated with rare, minor complications. These include mild pain, swelling, and mucosal ulceration that generally resolves unaided within 1-2 months.
Genioglossal advancement with hyoid suspension may be complicated by bleeding or infection in the floor of the mouth, Warthin duct injury, dental trauma, neck hematoma, pharyngocutaneous fistula, and wound infection.
Maxillary-mandibular advancement procedures may result in injury to the lingular neurovascular bundle. Most sensory impairments resolve over time. Cosmesis is generally not a problem.
The complications of tracheotomy include bleeding, pneumothorax, subcutaneous emphysema, and formation of peristomal scar tissue. Early tube dislodgment can occur and may result in hypoxia and death if not promptly replaced.
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Further Reading
Clinical guidelines
University of Texas, School of Nursing, Family Nurse Practitioner Program. Screening for obstructive sleep apnea in the primary care setting. Austin (TX): University of Texas, School of Nursing; 2006 May. 13 p.
Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of obstructive sleep apnea in adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Jun. 55 p.
Scottish Intercollegiate Guidelines Network (SIGN). Management of obstructive sleep apnoea/hypopnoea syndrome in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003 Jun. 35 p.
Keywords
snoring and obstructive sleep apnea, obstructive sleep apnea, snoring, surgery for obstructive sleep apnea, OSA, surgery for sleep-disordered breathing, obstructive apnea, peripheral apnea, sleep apnea, sleep-induced apnea, Ondine curse, Ondine's curse, frequent awakening, daytime sleepiness, sleep disorder, apnea index, respiratory disturbance index, RDI, uvulectomy, nasal reconstruction, adenotonsillectomy, palatal implants, uvulopalatopharyngoplasty, UPPP, UP3, genioglossal advancement with hyoid myotomy, maxillary-mandibular advancement, bimaxillary advancement, palatal advancement, tongue-base surgery, midline glossectomy, tracheostomy, continuous positive airway pressure, CPAP, bilevel positive airway pressure, Bi-PAP, Pillar system, Pillar procedure, transpalatal advancement pharyngoplasty, thyrohyoid suspension, radiofrequency ablation, tracheotomy
