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Surgical Treatments for Sleep Apnea

SCOFA-Surgery-OSA-2

 
Medically reviewed by
Dacelin St Martin, MD
Triple board-certified in Sleep Medicine,
Internal Medicine, and Pediatrics.

 
 
First-Line Therapies | Surgical Management | Upper Pharyngeal Procedures | Lower Pharyngeal and Laryngeal Procedures | Upper Airway Stimulation | Craniofacial Surgery | Tracheostomy  

 

Overview 

With obstructive sleep apnea (OSA), muscles supporting the soft tissues within the oral cavity relax and block the upper airway, causing breathing to repeatedly pause while sleeping.

This obstruction causes airways to narrow or close, leading to lower oxygen levels in the blood. The brain detects these lower levels and sends signals to the body’s muscles, rousing one from sleep so that they can get the air their body needs. [1]

Symptoms of OSA are typically reported by a sleep partner or identified upon medical observation. At times, the patient may also report daytime sleepiness, as it is a primary symptom of OSA; however, other common symptoms include:

  • Loud snoring
  • Gasping, choking, and snoring while sleeping
  • Interruptions in breathing
  • Morning headaches
  • Constant arousal from sleep [2-3]

OSA can affect women and children. Older males are more commonly diagnosed with this condition, although menopausal women are affected at almost the same rate. 

Additionally, OSA is the most common sleep-related breathing disorder. It’s diagnosed in 10 to 15 percent of females and 15 to 30 percent of males approximately. [4] 

To diagnose OSA, clinicians will evaluate the patient’s abnormalities within the mouth, throat, and nose. A polysomnography (PSG), or sleep study, may be used to monitor the brain, lung, heart, breathing, arm and leg movements, and blood oxygen levels while the patient sleeps. [5]SCOFA Surgery OSA

 

First-Line Therapies 

Weight loss

Fat in the upper respiratory tract causes narrowing of the airway, and as such, medical experts believe that weight loss can help manage OSA. 

A study explored the effects of weight loss on OSA for one year that included 264 participants who were randomly assigned to two different studies:

A) An intensive lifestyle intervention behavioral weight loss program developed specifically for obese patients with type 2 diabetes
B) Three group sessions related to effective diabetes management. 

The intensive lifestyle intervention participants lost more weight at one year than the other group of participants. The researchers concluded that physicians and their patients could expect a higher rate of weight loss when offered clinically relevant improvements in OSA among obese patients with type 2 diabetes. [6]

CPAP

Continuous positive airway pressure therapy (CPAP) uses a machine to help those affected by OSA breathe easier during sleep. This process increases air pressure in the throat so that the airway doesn’t collapse upon inhalation. 

CPAP is considered the gold standard for OSA treatment. Despite the many options available to treat OSA, one study that looked at numerous methods of treating OSA determined that CPAP is one of, if not the most, efficacious management modality for OSA. [7]

While non-surgical means may help remedy OSA for some persons, others may require second-line treatments, like surgery or an oral appliance. Determining factors include:

  • Severity of symptoms
  • CPAP intolerance
  • Perioperative risk factors
  • Health and functionality of the aerodigestive tract

 

Surgical Management  

While non-surgical methods may help remedy OSA for some persons, others may require surgical intervention. Let’s look at a few of the surgical options available to treat OSA.

Nasal Surgery 

Nasal surgery is often used with CPAP, an oral appliance, or other surgical therapies to manage OSA. 

There is not one specific type of nasal surgery involved in treating OSA, but they all reduce airflow resistance by increasing the size of the nasal passage. 

Nasal surgery makes it easier for one to tolerate an oral appliance or CPAP better. The European Respiratory Journal published a study indicating that nasal surgery alone is inefficient in remedying OSA but is instrumental as an adjunct therapy to CPAP. [8]

 

Upper Pharyngeal Procedures

Uvulopalatopharyngoplasty

For some patients, the removal of tonsils, adenoids, and other oral tissue may be necessary. This procedure is called uvulopalatopharyngoplasty (UPPP). Currently, UPPP is the most commonly performed surgical procedure for treating OSA in adults. [9]

Tonsillectomy 

Tonsils are two oval-shaped pads of tissue located on either side of the throat. When these structures become inflamed, the condition is referred to as tonsillitis and can give rise to a range of other issues. To treat tonsillitis, a surgical procedure known as tonsillectomy is typically done. In some cases, a doctor may consider a tonsillectomy as a management option for OSA since swollen tonsils can cause apnea. [10]

Adenoidectomy 

The adenoids are glands located above the roof of the mouth and are instrumental in helping to protect the body from pathogens; however, they sometimes become swollen. Therefore, similarly to the tonsils, they get removed surgically, as their swollen state can hinder breathing. This procedure is commonly used for children affected by OSA, but on occasions, adults undergo this procedure. [11]

 

Lower Pharyngeal and Laryngeal Procedures

Tongue Reduction and Advancement

The tongue falling backward and blocking the oral cavity, including the throat, is the number one cause of OSA. Additionally, if the tongue is too fast, it can obstruct breathing without even falling backward. Consequently, tongue reduction is the primary surgical therapy for managing OSA-related abnormal enlargement of the tongue or a fat tongue. [12]

Tongue advancement involves implanting tissue to splint or anchor the tongue and make it firmer to reduce the likelihood of it falling backward during sleep. A pilot study determined that adjustable tongue advancement is a feasible and relatively safe way to reduce snoring in selected patients with moderate to severe OSA and CPAP intolerance. [13]

Epiglottis Correction

The epiglottis is a flap of tissue at the base of the tongue and covers the larynx and lungs during swallowing to prevent food or saliva from entering it. 

Epiglottis correction becomes necessary when there is malformation or inflammation and is used in conjunction with surgery to relieve upper pharyngeal obstruction that hinders breathing while asleep. [14]

 

Upper Airway Stimulation

Upper airway stimulation, offered through a company called Inspire, is the only FDA-approved OSA treatment that works within the body to treat the actual cause of sleep apnea. It does not require the use of a mask or hose, requiring only the click of a button after device placement. The device works inside the body while you sleep, and is turned on with the click of a remote.

OSA occurs when the muscles supporting the soft tissues within the oral cavity and throat, such as the tongue and soft palate, become relaxed. So, upper airway stimulation works to open the airway when relaxation takes place while the user is sleeping. Doing so facilitates easier and more normal breathing. [15]

This technology uses hypoglossal nerve stimulation (HNS) therapy, a newer treatment modality to remedy OSA. Hypoglossal nerve stimulation therapy stimulates the nerve that is responsible for tongue movement. 

Here’s how it Works

  1. The nerve stimulator device and battery pack are implanted under the skin in the chest.
  2. The device is connected to the nerve that stimulates the tongue and space in the ribs.
  3. After four weeks, the doctor will activate the device, and you are provided with a remote that controls the device. 
  4. After activation, the device begins monitoring your breathing.
  5. Before falling asleep, you can switch on the device.
  6. When turned on, hypoglossal nerve stimulation therapy causes the main tongue muscles to stiffen.
  7. When the tongue muscles stiffen, they prevent the tongue from relaxing, falling backward, and blocking airflow while sleeping. 
  8. When the user wakes up, they use the same remote to turn off the device. [16]

 

Scientific Evidence 

In a clinical literature review, investigators concluded that data from the STAR trial suggests that a subset of OSA patients can achieve significant therapeutic benefits from hypoglossal nerve stimulation induced by upper airway stimulation. [17]

In another clinical review, it was determined that HNS obtained a high surgical success rate; related to the device implanted. They further state that the upper airway stimulation device provides an effective and safe surgical treatment for select adult patients affected by moderate to severe OSA who had difficulty with other treatment modalities. [18]

One study looked at the objective and patient-reported outcome after twelve months of implantation. The results led researchers to assert that, in routine clinical practice, upper airway stimulation is a safe and efficient management option for patients with OSA. [19]

From the information gathered, Sage Journals reports that after using the upper airway stimulation device, 90% of bed partners reported no snoring or soft snoring, and there is also a 79% reduction in OSA events. [20]

 

Craniofacial Surgery

Maxillomandibular advancement (MMA) is performed by moving the upper and lower parts of the jaw forward from the rest of the facial bones.

This procedure causes the attached soft tissues, such as the soft palate, to also move forward.

Consequently, the chances for obstruction lessen as the space behind the tongue and soft palate becomes larger. 

 

Tracheostomy

With this procedure, metal or plastic tube is placed in a surgical opening made in the neck. 

A tracheostomy is typically the last resort if all else has failed and the patient is affected by chronic OSA. 

Air will flow through the tube, and as such, a blocked throat caused by relaxed muscles will not affect breathing. [21]

 

Conclusion 

OSA is serious, as there are instances where it may become severe and life-threatening. Therefore, at the earliest sign of sleep disturbance, one must seek medical attention.

Prompt intervention helps prevent worsening the condition and helps restore sleep and health. 

 

References: 

  1. Slowik, J. M., & Collen, J. F. (2021, June 7). Obstructive Sleep Apnea. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459252/
  2. Chervin, R. D. (2000). Sleepiness, Fatigue, Tiredness, and Lack of Energy in Obstructive Sleep Apnea. Chest, 118(2), 372–379. https://pubmed.ncbi.nlm.nih.gov/10936127/
  3. Russell, M. B., Kristiansen, H. A., & Kværner, K. J. (2014). Headache in sleep apnea syndrome: Epidemiology and pathophysiology. Cephalalgia, 34(10), 752–755. https://pubmed.ncbi.nlm.nih.gov/24928423/
  4. T;Palta, Y. (2012). Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort study. WMJ : Official Publication of the State Medical Society of Wisconsin, 108(5). https://pubmed.ncbi.nlm.nih.gov/19743755/
  5. Kapur, V. K., Auckley, D. H., Chowdhuri, S., Kuhlmann, D. C., Mehra, R., Ramar, K., & Harrod, C. G. (2017). Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine, 13(03), 479-504. https://pubmed.ncbi.nlm.nih.gov/28162150/
  6. Foster, G. D. (2009). A Randomized Study on the Effect of Weight Loss on Obstructive Sleep Apnea Among Obese Patients With Type 2 DiabetesThe Sleep AHEAD StudyEffect of Weight Loss on Obstructive Sleep Apnea. Archives of Internal Medicine, 169(17), 1619. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879275/
  7. Calik, M. W. (2016). Treatments for Obstructive Sleep Apnea. Journal of Clinical Outcomes Management : JCOM, 23(4), 181–192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4847952/
  8. Koutsourelakis, I., Georgoulopoulos, G., Perraki, E., Vagiakis, E., Roussos, C., & Zakynthinos, S. G. (2008). Randomised trial of nasal surgery for fixed nasal obstruction in obstructive sleep apnoea. European Respiratory Journal, 31(1), 110–117. https://erj.ersjournals.com/content/31/1/110 ‌
  9. Carvalho, B., Hsia, J., & Capasso, R. (2012). Surgical Therapy of Obstructive Sleep Apnea: A Review. Neurotherapeutics, 9(4), 710-716. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480570/
  10. Reckley, L., Fernandez-Salvador, C., & Camacho, M. (2018). The effect of tonsillectomy on obstructive sleep apnea: an overview of systematic reviews. Nature and Science of Sleep, Volume 10, 105–110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5894651/
  11. ‌Domany, K. A., Dana, E., Tauman, R., Gut, G., Greenfeld, M., Yakir, B.-E., & Sivan, Y. (2016). Adenoidectomy for Obstructive Sleep Apnea in Children. Journal of Clinical Sleep Medicine, 12(09), 1285–1291. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990952/
  12. Cielo, C. M., Duffy, K. A., Vyas, A., Taylor, J. A., & Kalish, J. M. (2018). Obstructive sleep apnoea and the role of tongue reduction surgery in children with Beckwith-Wiedemann syndrome. Paediatric Respiratory Reviews, 25, 58–63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5890299/
  13. ‌Hamans, E., Boudewyns, A., Stuck, B. A., Baisch, A., Willemen, M., Verbraecken, J., & Van de Heyning, P. (2008). Adjustable Tongue Advancement for Obstructive Sleep Apnea: A Pilot Study. Annals of Otology, Rhinology & Laryngology, 117(11), 815–823. https://pubmed.ncbi.nlm.nih.gov/19102126/
  14. ‌Salamanca, F., Leone, F., Bianchi, A., Bellotto, R. G. S., Costantini, F., & Salvatori, P. (2019). Surgical treatment of epiglottis collapse in obstructive sleep apnoea syndrome: epiglottis stiffening operation. Acta Otorhinolaryngologica Italica, 39(6), 404–408. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6966774/
  15. How it Works. (2019). Inspire Sleep. https://www.inspiresleep.com/
  16. Woodson, B. T., Strohl, K. P., Soose, R. J., Gillespie, M. B., Maurer, J. T., de Vries, N., Padhya, T. A., Badr, M. S., Lin, H., Vanderveken, O. M., Mickelson, S., & Strollo, P. J. (2018). Upper Airway Stimulation for Obstructive Sleep Apnea: 5-Year Outcomes. Otolaryngology–Head and Neck Surgery, 159(1), 194–202. https://journals.sagepub.com/doi/full/10.1177/0194599818762383
  17. What is Hypoglossal Nerve Stimulation Therapy for Sleep Apnea. (2016, July 12). What is Hypoglossal Nerve Stimulation Therapy for Sleep Apnea? Advanced Sleep Medicine Services, Inc. https://www.sleepdr.com/the-sleep-blog/what-is-hypoglossal-nerve-stimulation-therapy-for-sleep-apnea/
  18. Wray, C. M., & Thaler, E. R. (2016). Hypoglossal nerve stimulation for obstructive sleep apnea: A review of the literature. World Journal of Otorhinolaryngology – Head and Neck Surgery, 2(4), 230–233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698546/
  19. Costantino, A., Rinaldi, V., Moffa, A., Luccarelli, V., Bressi, F., Cassano, M., Casale, M., & Baptista, P. (2019). Hypoglossal nerve stimulation long-term clinical outcomes: a systematic review and meta-analysis. Sleep and Breathing, 24(2), 399–411. https://pubmed.ncbi.nlm.nih.gov/31418162/
  20. Steffen, A., Sommer, J. U., Hofauer, B., Maurer, J. T., Hasselbacher, K., & Heiser, C. (2017). Outcome after one year of upper airway stimulation for obstructive sleep apnea in a multicenter German post-market study. The Laryngoscope, 128(2), 509–515. https://pubmed.ncbi.nlm.nih.gov/28561345/
  21. Carvalho, B., Hsia, J., & Capasso, R. (2012). Surgical Therapy of Obstructive Sleep Apnea: A Review. Neurotherapeutics, 9(4), 710–716. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480570/