For patients with obstructive sleep apnea (OSA), positive airway pressure (PAP) therapy is usually prescribed as first-line treatment, a recommendation supported by high-level evidence for efficacy of PAP in preventing upper airway collapse and relieving symptoms such as daytime sleepiness. In addition, there is mounting data suggesting that PAP therapy favorably impacts cardiovascular outcomes. However, some patients find it difficult to adhere to PAP therapy, prompting a substantial proportion to seek alternative treatment, including upper airway surgery.

Although surgery of the upper airway has been performed for decades as a treatment for OSA, its role in the management of OSA remains controversial. Reasons include the lack of high-level, controlled studies in the surgical literature and the absence of standardized criteria to define surgical “success.” On the other hand, one must acknowledge potential ethical and logistical limitations to controlled surgical studies and the contention that the “all or none” principle of eradication of OSA [i.e., an apnea-hypopnea index (AHI) < 5] as the standard of care is flawed and impractical for many patients. One may ask whether it’s preferable to wear PAP for a portion of a night or to undergo surgery which may not fully control sleep apnea but whose effects aren’t reliant upon user compliance.

Limitations to the maturation of this literature include the lack of a reliable pre-operative clinical assessment that predicts surgical outcome, difficulties in adjusting for surgical expertise and volumes, and biases that are inherent to surgeons and population samples that comprise this research. Cumulatively, there is a lack of a firm evidence base upon which the sleep medicine clinician can rely to guide management decisions in patients with OSA, though the American Academy of Sleep Medicine (AASM) published a systematic review, meta-analysis and practice parameter paper on the subject in 2010.¹

The general review of surgical procedures is as follows:

1. Soft Palatal Procedures

Soft palatal procedures serve to reduce or reconstruct the collapsible portions of the soft palate. The classic procedure is the uvulopalatopharyngoplasty, more commonly referred to as UPPP, first described by Fujita in 1981, which involves excision of the tonsils and posterior soft palate / uvula, and closure of the tonsillar pillars. The 2010 systematic review found that the AHI, on average, was reduced by only one-third and substantial residual apnea remained on post-operative follow up. Side effects include difficulty swallowing/nasal regurgitation, taste disturbances and voice changes. A large survey of the VA Administration records reported a 1-2% risk of a life-threatening adverse events and 0.2% risk of death following UPPP.

Laser assisted uvulopalatoplasty is an outpatient surgical technique involving a series of laser incisions and vaporizations designed to shorten the uvula and modify and tighten the soft palatal tissue. A 2001 AASM review showed outcomes similar to UPPP, with reductions in AHI well below 50%.

Upper airway radiofrequency treatment (RFA) has been used in the upper airway with and without temperature control of the probe tip. Prior to its use in the setting of OSA, this temperature controlled technique had been utilized in surgical procedures involving other organ systems, and was developed with the intent to precisely apply temperature controlled energy to target tissue while sparing adjacent tissues using a thermocouple on the probe tip. In one randomized trial comparing RFA with sham surgery and PAP, there was only a 21% reduction in the AHI, though the primary outcomes of that trial were vigilance testing (the active surgical group performed better) and quality of life (surgery and PAP both improved).

Soft palatal implants were devised as a less-invasive or lower morbidity procedure for treating the palate for mild to moderate OSA. In this procedure, Dacron rods are inserted into the soft palate under local anesthesia. The implants are not recommended for those with severe OSA, large neck circumference or a body mass index > 32 kg/m2. Small randomized trials show very modest reductions in AHI.

In recent years, there have been modifications to the classical pharyngeal procedures that show somewhat better outcomes, though in very select populations. Because collapse can occur at various sites along the upper airway, some have advocated a multi-level and/or multi-phase approach to the surgical treatment of OSA with multiple procedures during the same operation. These include MMA and RF treatments (discussed previously), and a variety of other combinations of procedures. The majority of these combine UPPP with a surgical procedure that involves surgery on the tongue, whether radiofrequency ablation, mid-line glossectomy, tongue advancement or tongue suspension.  

2. Maxillo-Mandibular Advancement

Maxillo-Mandibular Advancement (MMA)—a multilevel skeletal surgery designed to enlarge the velo-orohypopharyngeal airway without direct manipulation of the pharyngeal tissues. It  advances the anterior pharyngeal tissues (soft palate, tongue base, and suprahyoid musculature) attached to the maxilla, mandible and hyoid bone and is accomplished by LeFort I and bilateral sagittal split rami osteotomies that are stabilized with screws, plates or bone grafts.

The literature is limited to case series which are prone to bias, but the impact of MMA on OSA is promising, with a reduction in the AHI exceeding 80%. Importantly, the pre-operative surgical approach in these papers was surgeon-dependent; currently, the approach is yet to be standardized, though the field is actively exploring such pathways. Although no serious adverse events were reported in the literature, it is important to note that there has not been a systematic exploration of adverse outcomes and the findings rely entirely on author self-reporting. MMA is a lengthy and technically challenging procedure and presents inherent risks of dental malocclusion and facial neurosensory deficits.

3. Tracheostomy

Tracheostomy continues to have a role in the management of OSA, particularly in those whose disease is very severe or who have concomitant needs for mechanical ventilation. The procedure involves bypassing of the pharynx and soft tissues of the upper airway by creation of a stoma in the upper trachea caudal to the pharynx. Trach site care and the risk of respiratory infection necessitates the limitation of this procedure to select groups of patients.

Overall, the surgical data leave questions about specific sub-groups of patients unanswered. Outcomes in women, some minorities and those more than 50 years of age are lacking. Whether body weight imparts influence on outcomes is not clearly evident from the current dataset. Finally, there are little to no data of the effects of surgical procedures on cardiovascular outcomes in those with OSA.

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Reference

1. Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep 2010; 33:1396-407.

Keywords: Respiratory System, Sleep Apnea, Obstructive, Sleep Stages

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