Sleep Apnea (cont.)
Siamak N. Nabili, MD, MPH
Dr. Nabili received his undergraduate degree from the University of California, San Diego (UCSD), majoring in chemistry and biochemistry. He then completed his graduate degree at the University of California, Los Angeles (UCLA). His graduate training included a specialized fellowship in public health where his research focused on environmental health and health-care delivery and management.
In this Article
- Sleep apnea facts
- What is sleep apnea?
- What are the types of sleep apnea?
- What is central sleep apnea and what causes it?
- What is obstructive sleep apnea and what causes it?
- How common is obstructive sleep apnea?
- What are obstructive sleep apnea symptoms?
- What are some of the complications of sleep apnea?
- How is obstructive sleep apnea diagnosed and evaluated?
- What are the nonsurgical treatments for obstructive sleep apnea?
- What are the surgical treatments for obstructive sleep apnea?
- Why is it important to treat obstructive sleep apnea?
- Find a local Sleep Specialist in your town
What are the surgical treatments for obstructive sleep apnea?
There are many surgical options to treat obstructive sleep apnea. The type of surgery that is chosen is dependent on an individual's specific anatomy and severity of sleep apnea. People often want surgery because it promises a cure with a single treatment. Surgery sounds easier than losing 10 pounds and more convenient than wearing a dental appliance or mask every night. However, surgery is not the "miracle cure" either. Most surgeries are safe; however every surgery, no matter how small, carries risks. Most surgeries require time off from work to heal and some are quite painful for up to 2-3 weeks. Some of the potential general risks of surgery include:
- scar tissue,
- loss of work,
- change in voice,
- problems swallowing,
- failure to cure sleep apnea,
- anesthesia risks (including allergic reaction, stroke, heart attack, and death), and
- other unforeseen surgical complications.
Surgery should be considered only after all the risks, benefits, and alternatives to surgery are understood. Some insurance companies require a 3+-week trial of treatment with CPAP before they will even consider authorizing surgery for sleep apnea. This is not an unreasonable approach. CPAP, if tolerated, controls most sleep apnea, and this may be better better than surgical options. It is difficult to have a serious, permanent complication using CPAP as compared to the possibility of such a complication with surgery.
Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, obesity, or several of these areas at the same time. Each surgery's success rate is determined by whether or not a specific airway collapse or obstruction is prevented. Therefore, the ideal surgery is customized for each patient and depends on each patient's specific problem. Some surgical options include:
- nasal airway surgery,
- palatal and pharayngeal surgery (uvulopalatopharyngoplasty),
- upper airway stimulation therapy,
- tongue reduction,
- tongue repositioning or genioglossus advancement,
- hyoid suspension,
- maxillomandibular procedures,
- palatal implants,
- bariatric surgery, and
- combinations of the above.
Many people have several levels of obstruction and, therefore, these surgical techniques frequently are performed together (for example, uvulopalatopharyngoplasty with genioglossus advancement and hyoid suspension).
Nasal airway surgery
It is rare for obstructive sleep apnea to be caused by nasal obstruction alone. The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP. Nasal obstruction makes CPAP difficult if not impossible to tolerate. Surgery to open the nasal passages markedly improves tolerance to CPAP.
Palate and Pharyngeal Surgery (Uvulopalatopharyngoplasty [UPPP])
Various surgical procedures that stabilize the tissue at the roof of the mouth (palate) and walls of the throat (pharynx) have been described. The effectiveness of the procedures depends on the tissues involved with collapse of the airway in addition to what is happening elsewhere in the airway. Traditionally, a uvulopalatopharyngoplasty (UPPP) was developed. It is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese.
An UPPP operation is performed under general anesthesia and the patient is completely asleep. In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed. All of the surgical cuts are closed with stitches. UPPP may require an overnight stay in the hospital to monitor breathing and to control pain. UPPP is a painful operation similar to a tonsillectomy in an adult (tonsillectomy in children is less painful). Frequently, it is recommended for patients undergoing UPPP to take 10 days to 2 weeks off from work. In the postoperative period, people usually are on a liquid only diet and require liquid pain medication.
A UPPP is successful a majority of the time in preventing or decreasing obstructive sleep apnea. Studies also have demonstrated a decrease in mortality and decrease in risk of car accidents after UPPP. Some people who have a "successful UPPP" and fewer episodes of apnea, still have to use a CPAP after surgery to completely control their obstructive sleep apnea but it has also been shown to improve the quality of life in many individuals following surgery.
There are complications that are unique to UPPP.
- Bleeding in the area of the tonsils may occur up to 14 days after surgery in about 3% of people. Occasionally, a second operation is needed to stop this postoperative bleeding.
- If large amounts of scar tissue form with the healing that follows the surgery, in particular between the nose and back of the mouth, the scarring can result in an airway that is narrower than it was preoperatively. This can result in nasal and pharyngeal stenosis, a difficult problem to treat.
- Velopalatal insufficiency is another complication of UPPP. One job of the palate is to close the back of the nose and direct food and liquids down the throat during swallowing. If the palate is too short or it cannot move far enough back, sometimes liquids may enter the nose during swallowing. Velopalatal insufficiency frequently is a temporary problem after surgery, but it may become permanent in up to 2% of people.
- The uvula and palate are used in some languages (for example Hebrew and Farci) to produce guttural fricative sounds. After UPPP, that sound cannot be made and may make some words difficult to pronounce. The palate also closes the nose during speech to prevent a "nasal" sounding voice. Some changes in voice can be permanent after UPPP.
Upper Airway Stimulation Therapy (UAST)
A more recently developed surgical therapy involves implantation of a small generator that stimulates the hypoglossal nerve to the tongue and upper airway muscles during sleep. As described, obstructive sleep apnea for many patients occurs when the muscles of the airway relax naturally during sleep. UAST therapy attempts to overcome the impact of that muscle relaxation and subsequent obstruction.
Initial studies evaluating the ability of UAST to stabilize the airway have been very promising in select patients for 3 years and longer. One device is FDA-approved and provides therapy for patients who meet ceratin criteria, including previously failed medical therapy or CPAP. Implantation of the device includes the placement of a small generator in the anterior chest wall (similar to a cardiac pacemaker) with a stimulation lead placed around the hypoglossal nerve in one side of the neck. An additional sensory lead measures the breathing cycle to determine the timing of stimulation. Patients turn the device on before they go to sleep using a small hand held remote. There are no external hoses. This is considered the only surgery that does not alter the anatomy of the airway, however there are certain risks to consider and other contraindications.
Tongue reduction surgery
In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures. Midline glossectomy is one method to decrease the size of the tongue. Under general anesthesia, various devices may be used to cut a trough down the middle of the base of the tongue. The difficulty with this procedure is to remove enough tissue to prevent collapse without changing the natural functions of the tongue during speaking and swallowing. This procedure may be considered for people who have had collapse in the lower part of the airway below the palate and tonsils. Combined with other surgical procedures, midline glossectomy has been reported to be very successful.
The tongue base has also been the focus of surgical procedures to shrink the base of the tongue by scarring. Tissue that scars usually shrinks in size. For example, radiofrequency energy has been used to injure and scar the base of tongue. Usually the first treatment is performed under general anesthesia. A radiofrequency probe is placed in the muscle of the back of the tongue and energy is delivered. Over time, the tissue scars and shrinks. Frequently, several treatments are applied to the tongue. The later treatments can be performed in the setting of an office.
One complication of radiofrequency treatment is an infection or abscess in the tongue. An abscess in the tongue can narrow the airway and may require surgical treatment. A 17% reduction in volume of the tongue has been measured using this technique; however, this is generally not a successful technique if it is used alone. Therefore, reduction of the base of the tongue is frequently combined with UPPP or other procedures.
The genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. Genioclossus advancement or tongue suspension are types of surgical methods to reposition the tongue and relieve obstruction in the lower portion of the upper airway during sleep. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When the genioglossus muscle relaxes during sleep the airway narrows and collapses. There are several procedures that pull the tongue forward to enlarge the airway. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. Genioglossus advancement is performed under general anesthesia and requires cutting the bone and screwing it back in place. This usually is performed in combination with hyoid suspension or UPPP.
There also are less invasive methods to advance the genioglossus muscle. One method uses a stitch through the base of the tongue that attaches to a screw on the inside of the jaw. This method may be less invasive; however it is thought to be less effective and less permanent.
The hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures such as an UPPP or genioglossus advancement.
In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up. This procedure is very rarely done alone without other surgical procedures. Like other surgical procedures for obstructive sleep apnea, hyoid suspension has an adequate success rate when performed in an appropriately selected patient.
Maxillomandibular advancement is a surgical procedure that moves the jaw and upper teeth forward. This pulls the palate and base of the tongue forward and opens the airway. This procedure is best suited for a thin patient with a small jaw or patients with craniofacial, boney abnormalities. Both the jaw and maxillary bones are cut, moved forward, realigned, and plated into place. Care must be taken to keep the teeth aligned and preserve a normal bite and, therefore, the procedure usually is performed by an oral surgeon. The nerve to the front teeth and lip passes through the jawbone and is at risk for injury. Care must be taken to preserve the nerve so that there is normal sensation. In appropriate patients, maxillomandibular advancement has up to a 90% success rate for at least two years but longer term effectiveness is variable.
Palate implants stiffen the palate. In select patients, They may prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring. Palate implants have now been approved for people with mild sleep apnea; however, they are successful for only a small group of people with mild sleep apnea and palate collapse. A 250 pound man with an apnea-hypopnea index of 50 and decreases in blood oxygen to 85% will probably not be cured with a palate implant.
A tracheostomy is a procedure to bypass the narrowed airway. The trachea is the specialized tube that connects our larynx (voice box) to the lungs. It can be felt in the lowest part of the neck in most people. If the obstruction to airflow is occurring above the larynx, a tracheostomy can be inserted to direct airflow directly into the trachea. The tracheostomy tube is passed through the skin of the lower neck directly into the trachea. This surgery is performed under general anesthesia and requires observation postoperatively for complications in the intensive care unit.
Tracheostomy generally is reserved for morbidly obese patients with severe obstructive sleep apnea who are not candidates for other treatments. They usually can keep the tracheostomy tube capped during the day while breathing normally through their nose and mouth, and then open the tracheostomy tube at night. That way, they will have a normal voice and mouth breathing while awake, and breathe through the tracheostomy tube only at night.
A tracheostomy can be a temporary procedure, kept in place only as long as it is needed. It is easy to remove the tube, and the body will usually heal the skin and close the opening rather quickly. Tracheostomy has close to a 100% rate of cure for obstructive sleep apnea because it bypasses the problem in the upper airway. In mixed sleep apnea obstructive apneas resolve immediately, but in central apneas, which are due to metabolic changes caused by the obstructive apneas, it usually take some time for the apneas to resolve. Studies have shown improvements in sleepiness, hypertension, and cardiac risks following tracheostomy.
While it can be extremely effective, there are risks and complications of tracheostomy.
- The first is a psychosocial problem. Most people do not want to walk around with a tube coming out of their neck.
- The tracheostomy hole must be cared for and cleaned daily. Local infections or scar tissue can form around the hole on the inside or outside.
- Because of the tube, some people get recurrent infections in the bronchi (the tubes through which air passes from the trachea to the lungs).
- Severe life-threatening bleeding occurs rarely if the tube erodes into a major blood vessel in the neck.
- The trachea may stay narrowed at the tracheostomy site after the tube is removed. This may necessitate further surgery.
Most patients do not need to resort to a tracheostomy for sleep apnea; however it is a life-saving procedure for a few patients.
Bariatric (obesity) surgery is a type of surgery in obstructive sleep apnea. It is effective because most sleep apnea is caused by or worsened by obesity. Bariatric surgery is associated with a marked reduction in weight post-operatively. One study demonstrated an average weight loss of 120 pounds and an improvement in RDI from 96 to 11. All patients had at least a 55% decrease in their respiratory disturbance index.
Bariatric surgery is only an option for morbidly obese patients with severe obstructive sleep apnea. There is a 10% morbidity (illness, disease) rate associated with this type of surgery as well as a 1% mortality (death) rate. Patients can regain the weight they lost after surgery. Bariatric surgery, like the other surgical procedures that have been discussed, has significant risks and is not suitable for most patients with obstructive sleep apnea.
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