Part 3 - CPAP
Obstructive sleep apnea (OSA) is a disorder characterized by obstruction of the upper airway during sleep. This page is one of three describing treatment for OSA. In this page we will concentrate on various types of surgical techniques used to treat OSA. Other pages describe (1) lifestyle and dental appliances and (2) airway support using CPAP.
Sleep apnea is caused by a variety of different factors, and its treatment therefore often requires more than one specific option. As with all medical treatments, it is always best to begin with the safest and least invasive measures first. Weight loss and other lifestyle changes that improve sleep are crucial.
Certain individuals may have very clear anatomic problems causing OSA that are best treated surgically. Others may have tried a treatment such as CPAP but have not been able to tolerate it, and are interested in whether a surgical procedure may be helpful. Surgery is usually most effective if there is some clear anatomic problem that is worsening the sleep apnea. In this page we will first describe the various procedures available and then comment on their role in the overall treatment plan.
Since the success of surgery depends in large part on the relationship of the anatomy of the upper airway, it is useful to review this anatomy. A separate page covers most of this anatomy, and it may helpful to read this in conjunction with the discussion below.
Tonsillectomy
If the tonsils are large but not causing any problems, there is no need to remove them. However in some individuals tonsillar enlargement can be so severe as to block airflow through the oral cavity. When the tonsils are this large, they may also interfere with swallowing. If the tonsils alone are causing the obstruction at nighttime, most physicians would probably recommend they be removed. CPAP may help in this case as well, but if the main problem is mechanical obstruction from big tonsils, the success rate with tonsillectomy is quite high. Tonsillectomy does indeed have its risk, including bleeding, but it is overall a safe procedure in people of all ages. The actual operation is described a bit more at another page, though the discussion is focused on tonsillectomy done to reduce the risk of recurrent tonsillitis).
Uvulopalatopharyngoplasty (UPPP)
 This tongue twister of a name (also just called UP3) describes an operation in which the rear portion of the palate and the entire uvula is removed. The illustration to the left, the yellow area shows the tissue that is removed in this operation. If the tonsils have not been previously removed, a tonsillectomy is usually done in conjunction with this operation. This operation is done under a general anesthesia and almost always is followed by at least one night spent in the hospital.
This operation is performed if it is felt that collapse of the soft palate is playing a big role in causing sleep apnea. The most important aspect of this operation is removing enough tissue to reduce the symptoms, but no so much that the function of the palate is compromised. If too much of the palate is removed, the patient can have problems with food or liquids going up into the nose when swallowing. This often happens for several weeks in many people after UPPP, but in some cases it can be a longstanding problem.
Laser or Cautery Assisted Uvulopalatoplasty (LAUP or CAUP)
A LAUP ("lay-up") or a CAUP is an office-based procedure that is occasionally done for mild OSA, but actually used more in the treatment of snoring. In these similar procedures, instead of removing part of the palate, the surgeon makes a linear cut about 3/4" long on either side of the uvula, and may trim a portion of the uvula. As this incision heals, it causes some scarring of the back of the palate. This shortens the palate and reduces its tendency to vibrate. A LAUP or a CAUP is generally not felt to be sufficient for severe sleep apnea, but seems to help in mild cases. The cautery cuts as well as the laser, and there doesn't appear to be any large advantage to using one method over the other (except that lasers are a lot more expensive than cautery units).
Somnoplasty
Similar in principle to a LAUP or a CAUP is somnoplasty. Somnoplasty is a new procedure that uses radio frequency energy to heat tissue in the palate, causing formation of a lesion that gradually scars down and reduces the size and floppiness of the palate. Somnoplasty is also an outpatient procedure and is quite a bit less painful that a LAUP, CAUP, or UPPP. It is also not appropriate for anything more than mild sleep apnea.
A combined tonsillectomy and a UPPP is probably the most common surgical procedure done for most cases of sleep apnea. These operations deal mostly with problems in the upper portion of the oral cavity (i.e. the palate and the tonsils). In some cases, sleep apnea is also caused by backward displacement of the tongue, or by abnormalities of the bony structure in the skull. Several different operations can be used to correct these problems.
Genioglossus Advancement
Genioglossus advancement is a surgical procedure which attempts to pull the base of tongue forward in the oral cavity. Some muscles of the tongue are attached to inside of the lower jaw at the midline. This attachment help to prevent the tongue from falling backward. In a genioglossus advancement, a core of bone that includes this attachment is drilled out and advanced forward about 3/4", and then fastened in place with a plate. Some surgeons will also advance a bone in the upper throat called the hyoid, with the goal of bringing the entire base of tongue forward.
Mandibular Maxillary Osteotmies with Advancement (MMOA)
In this operation, cuts are made in the bone of the upper jaw (maxilla) and lower jaw (mandible), and both structures are advanced forward. This operation may be appropriate in people with skull abnormalities or with severe sleep apnea who have failed other treatments and operations.
Tracheotomy
A tracheotomy is an operation in which a hole is made in the neck and a breathing tube is placed directly into the windpipe. A separate page discusses various aspects of a tracheotomy. Since airflow completely bypass the upper airway, a tracheotomy is almost always effective in eliminating sleep apnea. However, a tracheotomy tube requires quite a bit of care and can be associated with various complications.
Summary of Surgical Options
The key to surgical treatment is choosing the right operation (if any) for the right person. In turn, this means trying to determine what part the anatomy is causing the problem. Even in the best situation, however, surgery is seldom as effective as treatment with CPAP. Most studies have shown that UPPP and tonsillectomy have a 50-60% success rate for OSA, compared with over 95% if CPAP is used. |
