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.
Doctor Verneuil grew up in Orange County and played high school water polo. He attended UCLA for his undergraduate degree in Kinesiology. Doctor Verneuil graduated from Mayo Medical School. He completed six years of Internship and Residency training in head and neck surgery at UCLA. He is Board Certified with the American Board of Otolaryngology.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
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:
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.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Sinus infection (sinusitis) signs and symptoms include headache, fever, and facial tenderness, pressure, or pain. Treatments of sinus infections are generally with antibiotics and at times, home remedies.
Hypothyroidism is any state in which thyroid hormone production is below normal. Normally, the
rate of thyroid hormone production is controlled by the brain at the pituitary.
Hypothyroidism is a very common condition and the symptoms of hypothyroidism are
often subtle.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Temporomandibular joint disorder, or TMJ, is a disorder of the temporomandibular joint(s) that causes signs and symptoms including ear pain, bite problems, headaches, dizziness, clicking sounds in the jaw, tinnitus and/or locked jaws. Behaviors or conditions that can lead to TMJ include teeth grinding or clenching, fingernail biting, habitual gum chewing, trauma to the jaw, stress, and occupational hazards. Treatment for TMJ may include heat, ice, a soft diet, antiinflammatory medications, physical therapy, stress management, occlusal therapy, correction of bite abnormalities, and surgery.
Polycythemia (elevated red blood cell count) causes are either primary (aquired or genetic mutations) or secondary (diseases, conditions, high altitude). Treatment of polycythemia depends on the cause.
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
It is thought that the tonsils and adenoids assist the body in fighting incoming bacteria and viruses by helping the body form antibodies. This is thought to be important only during the first year of life. Acute tonsillitis, strep throat, mononucleosis (mono), chronic tonsillitis, peritonsillar abscess, and hypertrophic tonsils and adenoids are all common problems involving the tonsils and adenoids. Treatment of tonsillitis and adenoids include antibiotics and other medications depending on the cause. In some cases, a tonsillectomy or adenoidectomy (the removal of the tonsils or adenoids) may be necessary.
Marfan syndrome is hereditary condition affecting connective tissue. A person with Marfan syndrome may exhibit the following symptoms and characteristics: dislocation of one or both lenses of the eye; a protruding or indented breastbone; scoliosis; flat feet; aortic dilatation; dural ectasia; stretch marks; hernia; and lung collapse. Though there is no cure for Marfan syndrome, there are treatments that can minimize and sometimes prevent some complications.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Pulmonary hypertension is an abnormal elevation of the pressure in the pulmonary circulation caused by the constriction of the blood vessels that supply blood to the lungs. Shortness of breath and dizziness are symptoms of pulmonary hypertension. Treatment involves diuretics, blood thinners, calcium channel blockers, and using supplemental oxygen to increase blood oxygen levels.
Snoring, like all other sounds, is caused by vibrations that cause particles in the air to form sound waves. While we are asleep, turbulent air flow can cause the tissues of the nose and throat to vibrate and give rise to snoring. Any person can snore. Snoring is believed to occur in anywhere from 30% of women to over 45% of men. People who snore can have any body type. In general, as people get older and as they gain weight, snoring will worsen. Snoring can be caused by a number of things, including the sleep position, alcohol, medication, anatomical structure of the mouth and throat, stage of sleep, and mouth breathing.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
High blood pressure (hypertension) means high pressure (tension) in the arteries. Treatment for high blood pressure include lifestyle modifications (alcohol, smoking, coffee, salt, diet, exercise), drugs and medications such as ACE inhibitors, angiotensin receptor blockers, beta blockers, diuretics, calcium channel blockers (CCBs), alpha blockers, clonidine, minoxidil, and Exforge.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Fatigue can be described in various ways. Sometimes fatigue is described as feeling a lack of energy and motivation (both mental and physical). The causes of fatigue are generally related to a variety of conditions or diseases for example, anemia, mono, medications, sleep problems, cancer, anxiety, heart disease, drug abuse, and more. Treatment of fatigue is generally directed toward the condition or disease that is causing the fatigue.
Sudden cardiac arrest is an unexpected, sudden death caused by sudden cardiac arrest (loss of heart function). Causes and risk factors of sudden cardiac arrest include (not inclusive): abnormal heart rhythms (arrhythmias), previous heart attack, coronary artery disease, smoking, high cholesterol, Wolff-Parkinson-White Syndrome, ventricular tachycardia or ventricular fibrillation after a heart attack, congenital heart defects, history of fainting, and heart failure, obesity, diabetes, and drug abuse. Treatment of sudden cardiac arrest is an emergency, and action must be taken immediately.
Narcolepsy, a chronic disease of the central nervous system causes have not been fully determined. Some theories include abnormalities in hypocretin neurons in the brain or an autoimmune disorder. Symptoms of narcolepsy include excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, sleep paralysis, disturbed nocturnal sleep, and automatic behavior. Diagnosis of narcolepsy is based on a clinical evaluation, specific questionnaires, sleep logs or diaries, and the results of sleep laboratory tests. Treatments of narcolepsy symptoms include medication and lifestyle changes.
Seizures are divided into two categories: generalized and partial. Generalized seizures are produced by electrical impulses from throughout the brain, while partial seizures are produced by electrical impulses in a small part of the brain. Seizure symptoms include unconsciousness, convulsions, and muscle rigidity.
Sleepwalking is a condition in which an individual walks or does other activities while asleep. Factors associated with sleepwalking include genetic, environmental, and physiological. Episodes of sleepwalking may include quiet walking to agitated running. Conditions that may have similar symptoms of sleepwalking, but are not include night terrors, confusional arousals, and nocturnal seizures. Treatment of sleepwalking generally include preventative measures. Medication may be prescribed if necessary.
A deviate septum is a condition in which the bone and cartilage that divide the nasal cavity of the nose in half (nasal septum) is significantly off center or crooked. The causes of a deviated septum can be congenital, or develop after a trauma or injury to the nose. Symptoms of a deviated septum include nasal congestion, recurrent sinus infections, nosebleeds, headache, facial pain, postnasal drip, snoring, and loud breathing. A deviated septum can be relieved with medications, and if necessary surgery, called a septoplasty.
Heart failure is caused by many conditions including coronary artery disease, heart attack, cardiomyopathy, and conditions that overwork the heart. Symptoms of heart failure include congested lungs, fluid and water retention, dizziness, fatigue and weakness, and rapid or irregular heartbeats.
Urinary incontinence in children (enuresis) is twice as common in boys as in girls and may occur during the daytime or nighttime. Nighttime urinary incontinence is also called bedwetting and sleepwetting. The cause of nighttime incontinence in children is unknown. Daytime incontinence in children may be caused by an overactive bladder. Though many children overcome urinary incontinence naturally, it may be necessary to treat incontinence with medications, bladder training and moisture alarms, which wake the child when he or she begins to urinate.
Hypersomnia is a condition where a person has excessive daytime sleepiness and trouble staying awake during the day. Treatment for hypersomnia includes medication, CPAP machines, and lifestyle changes.
When sleepiness interferes with daily routines and activities, or reduces the ability to function, it is called "problem sleepiness." A person can have problem sleepiness without realizing it. Symptoms of problem sleepiness include: consistently don't get enough sleep, or poor quality sleep, fall asleep while driving, struggle to stay awake when inactive (like watching TV or reading), have difficulty paying attention or concentrating at work, school, or home, have poor performance problems at work or school, have difficulty remembering things, have slowed responses, have difficulty controlling your emotions, and/or if you have to take naps on most days.
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