Sleep Apnea (cont.)
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 ten 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 three weeks. Some of the potential general risks of surgery
include:
- bleeding,
- infection,
- scar tissue,
- pain,
- 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 three weeks 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 is better than
all surgical options. It is difficult to have a serious, permanent complication
using CPAP as
compared to the possible 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 different for each patient and depends on each patient's specific
problem. Some surgical options include:
- nasal airway surgery,
- palate implants,
- uvulopalatopharyngoplasty,
- tongue reduction,
- genioglossus advancement,
- hyoid suspension,
- maxillomandibular procedures,
- tracheostomy,
- bariatric surgery, and
- combinations of the above.
Many people have several levels of obstruction therefore these surgerical
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 implants
Palate implants stiffen the palate. They 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 who have palatal collapse.
A study in people with an apnea-hypopnea index of less
than 24 demonstrated a 44% success rate in decreasing the apnea-hypopnea index
by 50% with a final apnea-hypopnea index less than 10 (Pilar Implant clinical
trial). Palate implants can be successful for a small group of people with mild
sleep apnea and palate collapse; however, 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.
Uvulopalatopharyngoplasty (UPPP)
Uvulopalatopharyngoplasty (UPPP) 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 usually requires an over
night 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
two weeks off from work. In the post-operative period, people usually are on a
liquid only diet and require liquid pain medication.
A UPPP is successful 50%-60% 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.
There are complications that are unique to UPPP.
- Bleeding in the area of the tonsils may occur up to 10 days after surgery in
about 1% of people. Occasionally, a second operation is needed to stop this
post-operative 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
pre-operatively. 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.
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. Laser midline glossectomy is one method to decrease the
size of the tongue. Under general anesthesia, a laser is 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 often is used for people who have
had a UPPP but continue to have obstructive sleep apnea. Combined with other surgical procedures,
laser midline glossectomy has been reported to be 70% 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 surgerical 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.
Genioglossus advancement
The genioglossus muscle is the muscle that attaches the
base of the tongue to the inside front of the jaw bone. 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 a 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.
Hyoid suspension
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
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. 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 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.
Tracheostomy
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 post-operatively 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, and is 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.
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 surgery
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.
Next: Why is it important to treat obstructive sleep apnea? »
- Tonsillectomy - Learn about the tonsillectomy or adenoidectomy surgery. Information on what to expect prior to surgery, during surgery, and recovery time from surgery.
- Congestive Heart Failure - Read about congestive heart failure symptoms like fatigue, abdomen, leg and ankle swelling, shortness of breath, sleeplessness, increased urination, nausea, abdominal pain, and decreased appetite.
- Tracheostomy - Read about tracheostomy procedure, used to create an opening in the neck to bypass an obstructed airway, clean or remove secretions, or more easily deliver oxygen to the lungs.
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