Chapter 17

Upper airway surgery in OSA

O. Marrone* and C. Vicini#

Summary
Surgical treatment of obstructive sleep apnoea (OSA) is mainly aimed at enlarging the upper airway and making it less susceptible to collapse during sleep in patients who do not want or cannot be treated by other means. Surgical success has commonly been defined as a o50% reduction in apnoea/ hypopnoea index (AHI) associated with a post-operative AHI of ,20 events?h-1. Subjective improvement ensues more often than resolution of respiratory disorders. Long-term relapse may occur. Pre-operatively, radiological and endoscopic tests may provide indications regarding the site of upper airway closure during sleep. Pharyngeal, hyoid and lingual surgery may show effectiveness when airway occlusion occurs at specific sites; their degree of success ranges 6070%. In adults, radiofrequency volume reduction of the tongue and/or the soft palate is convenient for subjects with mild OSA. Maxillomandibular advancement and tracheostomy are almost always effective, irrespective of the site of obstruction and the severity of OSA. In children, adenotonsillectomy and maxillary distraction osteogenesis are often followed by favourable outcomes, at least in non-obese subjects. Keywords: Ear, nose and throat surgery, maxillofacial surgery, minimally invasive surgery, pre-operative evaluation
*National Research Council, Institute of Biomedicine and Molecular Immunology, Palermo, and # Oral Surgery Section, Head & Neck Unit, Dept of Special Surgery, `, GB University of Pavia in Forli Morgagni and L Pierantoni Hospital, Forli, Italy. Correspondence: O. Marrone, Consiglio Nazionale delle Ricerche, Istituto di Biomedicina e Immunologia Molecolare, Via Ugo La Malfa, 153, 90146 Palermo, Italy, Email marrone@ibim.cnr.it

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Eur Respir Mon 2010. 50, 286301. Printed in UK all rights reserved. Copyright ERS 2010. European Respiratory Monograph; ISSN: 1025-448x. DOI: 10.1183/1025448x.00025309

ogether with weight loss, surgery was the first therapeutic approach proposed for obstructive sleep apnoea (OSA). Later, due to the effectiveness of treatment with continuous positive airway pressure (CPAP), and the high rate of failure of some widely used surgical procedures, the percentage of OSA patients submitted to surgical treatments decreased greatly. Subsequently, surgical techniques have been refined, new surgical procedures have been implemented, with the least effective ones being progressively abandoned, and more clinical and laboratory criteria that could predict the success of surgical treatment have been studied. Among modern surgical approaches, some have become very popular, such as radiofrequency (RF) procedures, whereas others have been more rarely applied, because they are more invasive and require great expertise and specialisation, such as maxillomandibular advancement (MMA) [1]. Even now, the scientific

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evidence for adopting upper airway surgery as a treatment for OSA is less than that for CPAP or oral appliances, and most criteria for predicting its success are only partially reliable. However, even taking into account these limitations, surgical treatment remains an important option for many subjects with OSA, particularly if they have peculiar upper airway anatomical features and do not want, or cannot undergo, other treatments.

Pathogenesis of OSA and role of upper airway surgery

Respiratory disorders that characterise OSA result from narrowing or closure of the upper airway during sleep, which may occur at a single or multiple levels, usually in the pharynx. Less typically and more rarely, the larynx is involved. Upper airway narrowing may be mild, determining flow limitation events with substantially preserved minute ventilation and without associated oxygen desaturation; more severe, causing hypopnoeas, which reduce alveolar ventilation and oxygen saturation; or extreme, leading to obstructive apnoeas. Snoring occurs due to vibrations of the soft palate, pharyngeal walls, tongue and/or epiglottis, and very often occurs during partial upper airway obstruction or between obstructive apnoeas. Anatomical and functional factors contribute variably to the pathogenesis of the obstructive events. Anatomical pathogenetic factors are abnormalities that increase upper airway resistance such that upper airway patency may be ensured only by an increased dilating muscular action that may be difficult to achieve during sleep [2]. Hypertrophy of structures surrounding the upper airway (such as nasal turbinate bones, tonsils, adenoids or the tongue) reducing its calibre are among the most typical and common findings in OSA. Among skeletal abnormalities, decreased palatal width, deficiency or downward and posterior rotation of the mandible, and low displacement of the hyoid bone are often observed; they can reduce the space for the tongue or displace it posteriorly, and alter the state of tension of dilating pharyngeal muscles, making their action less effective. Skeletal abnormalities, as well as external compression by hypertrophic adipose or muscular tissues surrounding the pharynx, may alter not only its size but also its shape [3]; an anteroposteriorly elongated pharynx with a short lateral axis, often observed in OSA patients, is more susceptible to occlusion since dilating muscles are less efficient in increasing lateral than anteroposterior pharyngeal dimensions [4]. The most severe skeletal abnormalities causing impaired maxillary and mandible development can mainly be observed in children with congenital syndromes (e.g. Treacher Collins syndrome and Pierre Robin sequence) [5]. Most surgical procedures for OSA modify upper airway anatomy, increasing its size and tending to put upper airway dilator muscles in to a more favourable condition in order to ensure upper airway patency, with the intention of making the upper airway less prone to collapse. Although altered size and shape of the upper airway may be surgically modified, other possible pathogenetic factors of OSA are not liable to be addressed by surgical treatment. They are often difficult to recognise pre-operatively, and may be a cause of surgical failure. Among functional factors, abnormal upper airway reflexes and histopathological alterations could predispose to OSA. They may partly represent long-term consequences of obstructive events during sleep, and may be reversible following treatment [6]; this suggests that surgical treatment could be more effective in patients with recent onset of OSA or who have already been treated with CPAP before the intervention. A weak downward stretching of the upper airway from the tracheobronchial tree, resulting in a smaller pharyngeal cross-sectional area [7], can be another important functional pathogenetic factor. It may play a role when lung volumes and inspiratory lung inflation are small, as is often the case in obese subjects; this may be a reason why surgical treatment is less effective in obesity. Among other pathogenetic functional factors, instability of control of breathing, particularly in severe OSA [8], and fluid shift from the legs to the neck while assuming a recumbent posture, particularly in sedentary subjects [9], may play important roles.

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Expectations from surgical treatment

Surgical treatment for OSA is sometimes performed to improve upper airway patency and make other treatments that may eliminate obstructive events during sleep easier to adopt or more effective. This typically applies to nasal surgery. When the nasal airway is obstructed, restoration of its patency, although not always ensuring nasal breathing, may permit patients to keep their mouth closed during sleep so that they can be more easily treated by an oral appliance, or with CPAP using a nasal mask. Besides, a decrease in nasal resistance may make CPAP effective at lower levels [10, 11], and increase adherence to treatment [12]. In these cases, surgical treatment can be considered useful even when it does not reduce OSA severity by itself. Some patients request surgical treatment just for their snoring. Surgical procedures are often more effective in reducing snoring (subjectively perceived) than apnoeas. However, heavy snoring is very often associated with at least some degree of OSA. Besides, in some non-apnoeic subjects, snoring could be associated with deleterious effects on sleep architecture, daytime symptoms or cardiovascular function. Therefore, before intervention, all patients requesting surgical treatment for snoring should undergo a careful general evaluation, and their respiratory function during sleep should be assessed. In this way, it could be established whether resolution of the snoring noise may or may not be the sole target of treatment. More commonly, surgical procedures are intended to reduce or eliminate obstructive events during sleep. In this case, surgery is rarely a first-choice treatment for adult OSA. Only the few patients with gross upper airway abnormalities reducing upper airway calibre, which are clearly the cause of airway obstruction during sleep, are candidates for surgery as a first-line treatment; in these subjects, removal of the obstructing tissues can often definitively treat OSA. In other patients, a complete cure is rarely obtained, and surgery is usually considered a possible alternative treatment.

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Classification of surgical procedures

Surgical procedures adopted in OSA may be classified according to various criteria (table 1). According to the possible target disease of the surgical operation, the surgical procedures can be distinguished as being in a group specifically devised for OSA, which are not applied in any other condition, and a group not specifically devised for OSA, which are well known in the surgical literature for cancer, inflammatory conditions and disproportionate anatomy, but are also applied in OSA, usually with special modifications. According to the obstruction site dependence of their efficacy, they may be divided into obstruction-site-dependent, requiring a preliminary identification of the sites of vibration or obstruction before being performed, and non-obstruction-site-dependent, i.e. able to remedy OSA of any severity irrespective of the precise site of obstruction inside the upper airway. Further classification may be carried out according to the site of intervention, mechanism of action or degree of invasiveness.

Pre-operative evaluation
Pre-operative evaluation is addressed at ascertaining patients willingness to undergo surgery and their clinical suitability for surgical treatment, and then at collecting information that may help in the choice of the procedure that may be most appropriate for treatment to be successful. Diagnosis of OSA must be established with nocturnal instrumental monitoring by an accepted methodology [13], in order to document the presence and severity of obstructive events during sleep. Severity of OSA is not always a contraindication for surgical treatment, particularly if

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Table 1. Classification of surgical procedures for obstructive sleep apnoea (OSA) Criteria Target disease Obstruction site dependence of efficacy Site of intervention Division Specific for OSA Not specific for OSA Site-dependent Not site-dependent Nose Nasopharynx Oropharynx Tongue Hyoid bone Maxillae/mandible Larynx Trachea Multisite Collapsing areas bypass Hypertrophic tissue removal Hypertrophic tissue shrinkage Tissue stiffening Muscle insertion relocation Tongue suture suspension Invasive Minimally invasive Main procedures UPPP, hyoid surgery Tracheostomy, MMA, T&A Palatal, lingual or hyoid surgery Tracheostomy, MMA Septoplasty, turbinoplasty Adenoidectomy Tonsillectomy, UPPP, palatal implants Glossectomy, lingual RFVR HTP, hyoid suspension GA, MMA, distraction osteogenesis Epiglottoplasty, aryepiglottoplasty Tracheostomy Multilevel surgery Tracheostomy T&A,UPPP, glossectomy Snoreplasty, lingual/soft palate RFVR Palatal implants, snoreplasty, RFVR GA, HTP, MMA Repose1# UPPP, HTP, glossectomy, MMA LAUP, RFVR, palatal implants
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Mechanism of action

Invasiveness

UPPP: uvulopalatopharyngoplasty; MMA: maxillomandibular advancement; T&A: adenotonsillectomy; RFVR: radiofrequency volume reduction; HTP: hyoidthyroidpexia; GA: mandibular osteotomy with genioglossus advancement; LAUP: laser-assisted uvulopalatoplasty. #: Frontier Medical Group, Blackwood, UK.

patients are well selected based on the anatomical characteristics of their upper airway [14, 15]; rather, it may be an indication for the more aggressive procedures. Indeed, minimally invasive procedures, which are associated with very little risk and rare side-effects, have proved of little help for severe forms of OSA. Comorbid conditions may contraindicate surgical treatment. The age of the patient must be considered, since anatomical upper airway abnormalities are less evident in late-onset OSA, and lower rates of success of surgical treatment have been reported in old subjects [16]. Obese subjects are worse candidates for surgical treatment than non-obese subjects; obesity is a risk factor for OSA [17], and is associated with a narrow upper airway lumen independently of structural anatomical abnormalities. A pre-operative anaesthesiological assessment is appropriate, particularly when general anaesthesia and intubation are required; OSA subjects are at increased risk of difficult tracheal intubation [18], and administration of some drugs commonly used to induce anaesthesia or to control post-operative pain may be followed by deleterious side-effects [19]. After the general characteristics of the patients have been examined, their upper airway and craniofacial characteristics must be evaluated in order to identify the most probable site of airway vibration or occlusion during sleep, and possibly to select a surgical procedure accordingly. Following the classification of FUJITA [20], three main types of pharyngeal obstruction may occur: type I, involving the upper part of the oropharynx; type II, involving both upper and lower pharyngeal regions; and type III, involving a low pharyngeal portion. Approximately 15% of OSA subjects show bulky upper airway lesions (such as tumours and marked soft tissue hypertrophy) whose surgical correction usually leads to a full recovery from respiratory disorders [21, 22]; in these patients, surgery is the first treatment option for OSA. In the great majority of cases, upper airway abnormalities are less marked, and the success of surgical

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treatment less predictable. In these patients, surgery is usually taken into consideration as a possible treatment for sleep respiratory disorders after other treatments have been tried and refused, or found to be poorly effective [13]. Inspection of upper airway and facial characteristics is commonly performed by every physician evaluating patients with OSA. Gross abnormalities, such as a markedly deviated nasal septum, major abnormalities in maxillary or mandibular development, or tonsillar hypertrophy, can be easily identified. Staging systems have been elaborated to describe some of the features that may be observed (fig. 1). According to the classification of FRIEDMAN et al. [23], four different scores are given when assessing the relationship between tongue and soft palate: the first score identifies a fully visible soft palate and high chance of airway occlusion at a high oropharyngeal level; the last score represents a totally hidden soft palate and a high probability of retrolingual occlusion during sleep. Similarly, tonsil size may have five different scores, with the first one identifying small hardly visible tonsils and the last one large kissing tonsils. In nonmorbidly obese subjects, a fully visible soft palate associated with large tonsils is considered predictive of a high probability of success for uvulopalatopharyngoplasty (UPPP) with tonsillectomy, whereas lower palate position may be an indication for other surgical procedures, enlarging lower portions of the pharynx [24]. Several different instrumental examinations have been proposed for the pre-operative evaluation of upper airway characteristics and possible site of obstruction in OSA patients. Fibreoptic endoscopy permits performance of more accurate inspection of the upper airway, from the nose to the larynx, than simple clinical inspection, and a better appreciation of the amplitude ller manoeuvre may be of the upper airway lumen at different levels. During endoscopy, a Mu performed in order to visualise sites of upper airway occlusion, but the contribution of this method to predicting the success of surgical treatment is limited, mainly because the sites of occlusion that are observed during wakefulness may be different from the spontaneous sites of occlusion during sleep [25]. Sleep endoscopy consists of a dynamic observation of the upper airway during induced sleep or anaesthesia [26], and is particularly useful for revealing cases of lateral pharyngeal wall collapse or epiglottic closure [27]. The application of this technique increases the rate of success of surgical

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a)

b)

c)

d)

e)

f)

g)

h)

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Figure 1. Scoring for ad) tongue position, and ei) palatal tonsil size. The scores range from a) a fully visible soft palate and high chance of airway occlusion at a high oropharyngeal level to d) a totally hidden soft palate and a high probability of retrolingual occlusion during sleep; and e) small hardly visible tonsils to i) large kissing tonsils. Reproduced from [23] with permission from the publisher.

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treatments, although unexpected cases of surgical failure following selection of patients based on this technique can still be observed [28]. Lateral radiographic cephalometry is performed in order to evaluate the size, shape and interrelationships between bones enclosing upper airway structures, as well as to appreciate the length of the uvula and the pharynx, and width of the airway space behind the soft palate and the tongue [29]. Cephalometric evaluation is very useful as a pre-operative examination before maxillomandibular surgery. Before other surgical procedures, it has a much more limited value; a long distance between the mandible and the hyoid bone could contraindicate UPPP [30]. Computed tomography and magnetic resonance imaging, performed with various techniques, have also been used, although they do not yet have surgical validation. They produce more accurate images of soft tissue than cephalometry, and can provide precise measurements of crosssectional areas at different levels of the upper airway, or even its full three-dimensional reconstruction [3]. They have also been tested for dynamic visualisation of the upper airway during both wakefulness and sleep. Today, they are used mainly for static measurements during wakefulness. Unlike previous examinations, making multichannel pressure measurements during sleep is not an imaging examination, but, by means of pressures recorded during sleep at different levels of the upper airway, it provides information about the lowest site of occlusion of the upper airway during obstructive apnoeas [31]. This test provides little data actual pathology, and so far has had limited application. In summary, there is now a large choice of tests for evaluating upper airway size, shape and function that can help in the choice of the most appropriate surgical procedure and to predict its success. Not all of them have been tested as predictive examinations. Some of them have been demonstrated to reduce rate of failures of surgical procedures, but the outcome of surgery still remains partly unpredictable. Pre-operative assessment may sometimes be misleading due to differences in airway behaviour between wakefulness and sleep, changes in site of occlusion with sleep state or posture, difficulties in identifying multiple sites of occlusion, or, probably, to a change in site of occlusion following surgery.

Evaluation of the success of surgical treatment

A 50% reduction in apnoea/hypopnoea index (AHI) was initially proposed as criterion for identifying responders to surgical treatment [32], but was soon abandoned because some of the so- called responders still showed an unacceptably high AHI following treatment. Subsequently, several criteria for defining the success of surgical treatment, based on various polysomnographic and, sometimes, clinical criteria, were proposed. Today, there remains no uniform definition for the success of surgical treatment [33]. Since the late 1980s, the most commonly used criterion for surgical success in adults has been a post-operative reduction in AHI of o50% associated with an AHI of ,20 events?h-1. It was initially adopted when treatment with CPAP in patients with an AHI of ,20 events?h-1 was very uncommon [34], and, subsequently, use of this criterion has become widespread. Like other criteria, it has been heavily criticised by some authors, claiming that an AHI of 20 events?h-1 is still indicative of moderate OSA, and that OSA cure may be recognised only when the AHI drops below 10 or even 5 events?h-1 [35]; such a result can be achieved with CPAP treatment, but is rarely obtained with any surgical procedure except tracheostomy. However, in patients who would otherwise not be treated because they do not accept CPAP or cannot take advantage of other treatments, a substantial, even if incomplete, improvement in respiratory disorders and symptoms may be considered a valuable effect [36]. In children, the most common criterion adopted for defining success of surgery has been a fall of AHI to ,5 events?h-1 [37]. As lower AHIs are found in normal children than in adults, and an AHI of ,5 events?h-1 does not exclude a diagnosis of OSA [38], this criterion is not exempt from criticism.

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At present, improvements in symptoms, particularly sleepiness, quality of life and health indicators such as blood pressure or inflammatory markers, are more and more often considered important indices for the evaluation of the success of any OSA treatment. However, a large number of patients experience subjective improvement following surgery despite negligible changes in AHI [3941]. Owing to the important placebo effects associated with surgery, as with any treatment of OSA, and the possible, although still discussed, detrimental effects of respiratory disturbances per se, it is necessary to include polysomnographic indices in any evaluation of surgical success. In addition to an early post-operative polysomnographic assessment following wound healing, a follow-up is recommended, since some relapse of nocturnal respiratory disorders has been observed in the long term, at least after some surgical procedures, even without weight increase [42, 43]. In the present chapter, the success of surgery in adults is defined according to the most commonly used criterion as a o50% reduction in AHI associated with a post-operative AHI of ,20 events?h-1.

Surgical procedures
Surgical procedures, listed according to the site of intervention and their indications, are listed in table 2.

Nasal surgery
Turbinoplasty, septoplasty and functional endoscopic sinus surgery are some of the operations that can be performed to improve nasal patency in patients with an obstructed nose. Several, mostly uncontrolled, studies have shown improvements in quality of life, subjective sleepiness, subjectively perceived snoring and quality of sleep following nasal surgery. Instrumental recordings have shown variable effects on sleep architecture and snoring, and only rare cases of adequate treatment of sleep-related breathing disorders [44]. When evaluated in the same subjects, subjective improvement was often associated with an unmodified AHI [41, 45, 46]. Therefore, although nasal surgery alone is considered inadequate for treatment of the great majority of patients with OSA, it has been hypothesised that there could be a small subpopulation of OSA patients who can respond to this treatment, but who cannot yet be identified in advance [44]. In subjects treated by CPAP, nasal surgery may reduce the pressure needed for treatment [10, 11] and improve adherence to treatment [12]. Therefore, it may be considered for patients with a high nasal resistance and high CPAP needs who are intolerant of CPAP treatment.

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Naso-oropharyngeal surgery: adenotonsillectomy

Adenotonsillectomy represents the most common treatment modality for childhood OSA. Since the 1990s, the more common performance of post-operative polysomnography than in the past has led to the recognition that adenotonsillectomy results in an unsatisfactory resolution of respiratory disorders in a substantial percentage of children. A recent meta-analysis not including high-risk groups (morbidly obese, syndromic, or neuromuscular patients) estimated that a fall in AHI to ,5 events?h-1 is obtained following adenotonsillectomy in 66% of children [37]. The outcome of surgery is influenced by coexistent risk factors for OSA, some of which are common, such as nasal obstruction and abnormal facial growth [47] or obesity [48], and some more rare, such as Downs syndrome [49] or syndromic craniosynostosis [50]. When such conditions are present, adenotonsillectomy is still often followed by some improvement in sleep respiratory function, but its rate of success is lower. One more factor associated with a high rate of persistence of OSA following adenotonsillectomy is a very high pre-operative AHI [51]. Improvements in quality of life or cognitive functions are common with adenotonsillectomy, but, as with other treatments, they are poorly correlated with changes in AHI [52].

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Table 2. Main otolaryngological and maxillofacial surgical treatments for obstructive sleep apnoea (OSA) and
their indications

Intervention site Nose

Main procedures Septoplasty Turbinoplasty Valvuloplasty FESS Adenoidectomy Tonsillectomy

Main indications For subjects with nasal obstruction, mainly to improve symptoms or feasibility of CPAP

Nasopharynx Oropharynx

Hyoid bone Tongue

Maxillae/mandible

Larynx Trachea Multisite

FESS: functional endoscopic sinus surgery; CPAP: continuous positive airway pressure; RFVR: radiofrequency volume reduction; GA: genioglossus advancement.

In adults, the success of tonsillectomy can be very high in the few non-obese subjects with very large tonsils and a fully visible palate and without other associated anatomical abnormalities of the upper airway [24]. In most cases, it is performed in association with palatal surgery.

Oropharyngeal surgery: UPPP and other invasive procedures involving the soft palate
UPPP is aimed at enlarging the upper airway at the retropalatal level, removing redundant tissues from the soft palate, uvula and posterior pillars [32]. Several variants of UPPP have been described. Its most important features are excision of the soft palate and uvula, with trimming and reorientation of the pharyngeal pillars, and it is usually associated with tonsillectomy (fig. 2). Post-operative pain and pharyngeal paraesthesia are the most common side-effects. Sometimes velar insufficiency occurs. Life-threatening complications are rare, probably not exceeding 1.5% [53]. UPPP was widely adopted in the past as single surgical treatment but, subsequently, a rate of

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Adenoid hypertrophy Tonsillar hypertrophy; in adults, mainly with other procedures Uvulopalatopharyngoplasty Retropalatal obstruction Uvulopalatal flap Retropalatal obstruction Lateral pharyngoplasty Lateral pharyngeal wall collapse Soft palate RFVR Alone, mainly for snoring Palatal implants Retropalatal obstruction in mild OSA Laser-assisted uvulopalatoplasty Not recommended Hyoid myotomy and suspension No longer used Hyoid myotomy with thyroidpexia Low pharyngeal obstruction Glossectomy Marked tongue hypertrophy; rarely used today Tongue RFVR Moderate macroglossia and Tongue suture suspension retrolingual obstruction, mainly in mild-to-moderate OSA Mandible osteotomy with GA Low pharyngeal obstruction; rarely performed alone Maxillomandibular advancement Mandibular deficiency, severe OSA with obstruction at multiple sites Distraction osteogenesis Mainly for children with narrow hard palate Epiglottoplasty Obstruction at the epiglottic level Tracheostomy Emergency situations; other treatments not feasible in severe OSA Variably combined procedures Obstruction at multiple sites in moderate-to-severe OSA

a)

failure of nearly 60% has been demonstrated among unselected patients, due to the high number of cases with hypopharyngeal airway closure during sleep [54]. Today, it is often performed in the context of multilevel surgery. With the uvulopalatal flap, unlike with UPPP, the uvula, rather than being excised, is retracted and sutured to the anterior part of the soft palate [55]. Conversely Z-palatoplasty can be considered an aggressive variant of UPPP for performance in previously tonsillectomised patients [56]. Transpalatal advancement pharyngoplasty requires removal of a small portion of the hard palate and forward suture of the soft palate [57]. Lateral pharyngoplasty is mainly addressed at preventing lateral pharyngeal wall collapse [58]. Although slightly better outcomes than with UPPP have usually been reported with these procedures, experience with most of them is rather limited.

b)

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c)

Oropharyngeal surgery: minimally invasive surgery of the soft palate

Laser-assisted uvulopalatoplasty is a surgical procedure initially introduced for treatment of snoring in an outpatient setting, under local anaesthesia, and later extended to treatment of OSA. It is often performed in multiple sessions. Using this technique, variable portions of Figure 2. a) Subject with palatine tonsil hyperplasia; and the same subject, b) immediately following uvulopalatopharyngoplasty with uvula, soft palate and tonsillar tonsillectomy, and c) after healing. pillars are incised and vaporised, and then left open to heal by scar formation. The poor average efficacy in reducing obstructive events, the severe post-operative pain and the possible severe sideeffects, such as pharyngeal stenosis following scarring, are some of the reasons why this procedure is not recommended by the American Academy of Sleep Medicine for OSA treatment [59].

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Palatal implants (Pillar1; Medtronic ENT, Jacksonville, FL, USA) are cylinders made of polyethylene terephthalate that are inserted in the soft palate, at the hard palate junction, usually under local anaesthesia as an office-based procedure. An inflammatory reaction develops around the implants. The resulting fibrotic reaction, together with the implants, stiffens the soft palate, making it less susceptible to fluttering and generation of snoring, and airway occlusion. It was initially introduced for treatment of simple snoring [60], and then its use was extended to subjects with mild or moderate OSA. It shows some effectiveness in reducing snoring, but effects on apnoeas are small [61]. Retropalatal siting of airway occlusion or sound generation is essential for its effectiveness against apnoeas or snoring. As a minimally invasive surgical procedure, this technique is usually safe and relatively easy to perform. RF surgery is a minimally invasive technique in which a needle electrode delivers a high-frequency electric current, increasing tissue temperature so as to provoke tissue coagulation and necrosis, and subsequently stiffening and volume reduction. It requires multiple sessions, but is quite precise and safe. RF surgery of the soft palate has been employed mainly for the treatment of snoring, usually with satisfactory results, although with frequent relapses. As an isolated procedure it has no clear indications in the treatment of OSA [62]. Injection snoreplasty is a technique in which a sclerosing agent is injected into the mucosa of the soft palate, making it stiffer [63]. It has been proposed for snoring treatment, but few data have been published in this regard.

Hyoid surgery
The hyoid bone is the site of insertion of several muscles influencing the size of the lower pharyngeal lumen. Hyoid myotomy and advancement was originally described with suspension to the lower mandible edge [34], and later with fixation to the superior margin of the thyroid cartilage (hyoidthyroidpexia), which better stabilises the hyoid bone and is associated with lesser morbidity [64]. These procedures are aimed at enlarging the lower pharyngeal space anteriorly and laterally. A wide range of success rates of hyoid surgery has been reported. Different criteria for patient selection, multiple variants of the technique and its association with other surgical procedures make it difficult to precisely define its effectiveness [65, 66].

Tongue surgery
Midline glossectomy [67], lingualplasty [68] and tongue base reduction with hyoepiglottoplasty [69] are aimed at increasing the lower pharyngeal lumen in subjects with macroglossia and retrolingual airway occlusion during sleep. They require perioperative tracheostomy, and may be followed by serious complications, such as alterations of speech, loss of taste and dysphagia, and so have been rarely performed, and there is little experience on their effects in OSA. Since the late 1990s, they have been replaced by less invasive techniques. Tongue suture suspension (Repose1; Medtronic ENT) is performed using nonresorbable threads, which are passed through the base of the tongue and fixed to the genioglossus tubercle under general anaesthesia [70]. Experience with this procedure is also scanty. According to the available data, its rate of success is not superior to RF volume reduction (RFVR) of the tongue, but it is more invasive and associated with higher morbidity [71]. Today RFVR of the base of the tongue, in association or not with palatal RF surgery, is the most commonly performed lingual surgical procedure for OSA. It is usually performed with an intraoral approach with local anaesthesia, and determines less pain and fewer and less severe sideeffects than most other surgical procedures for OSA. Therefore, despite the need for repeated sessions, it is gaining increasing popularity. Controlled studies in snorers [72] and in subjects with mild-to-moderate OSA [73] demonstrated significant effects of this procedure on subjective outcomes, such as snoring intensity or quality of life. Effects on AHI, although statistically demonstrated, were rather small [43]. In terms of successful treatment of sleep respiratory

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disorders, percentages ranging from 20 to 67% have been reported [40, 74]. Some loss of efficacy in the long term may occur [43, 74]. However, in subjects with mild OSA, who are often poorly compliant with CPAP, RF surgery may exhibit better outcomes than CPAP itself [40]. As an alternative to standard RF, tongue low-temperature RF molecular disassociation or coblation has been proposed. Using this technique, electrical energy is delivered to the tissues through a conductive medium, so as to generate a plasma of excited ionised particles and break chemical bonds. This technique has been claimed to be more successful than standard RF and to require shorter sessions [75]. The RF techniques have no indication in patients with severe tongue base hypertrophy. For such subjects, tongue base resection by transoral robotic surgery, which is less invasive and appears to have fewer side-effects than the old tongue resection procedures, is currently under investigation [76].

Surgery involving maxillae and mandible

With mandibular osteotomy with genioglossus advancement, a bony segment at the symphysis of the mandible, incorporating the genial tubercle, is isolated, advanced the thickness of the mandible, rotated and fixed to the anterior surface of the mandible (fig. 3) [34]. In this way, the genioglossus muscle, which inserts anteriorly on the advanced bone segment, is given more tension, making backwards collapse of the tongue during sleep more difficult [77]. This technique has been mostly performed in combination with other procedures, such as UPPP or hyoid surgery. Mandibular fracture may be one of its worst complications. Some minor degree of maxillomandibular deficiency is common in the OSA population. However, some patients with OSA show severe degrees of maxillomandibular deficiency, micrognathia or retrognathia. For such subjects, MMA is the most obvious form of treatment. Using this procedure, maxilla and mandible are displaced forwards, usually by 1012 mm, following intraoral osteotomy (fig. 4). As a result, the pharyngeal lumen is expanded throughout its length, both anteroposteriorly and laterally. Upper airway muscle insertions are also displaced such that they may exert a more effective dilating action [78, 79]. This procedure is one of the most invasive among those applied for OSA treatment, and requires a longer convalescence, but represents the most effective after tracheostomy, with rates of successful treatment of sleep respiratory disorders not ,75% or, according to some studies, even approximating to 100%; very high degrees of subjective improvement have also been reported [7882]. Among its possible complications, anaesthesia in the chin or cheeks, usually temporary, or malocclusion may occur. Orthodontic cooperation during the perioperative period is often necessary. In patients with severe maxillomandibular deficiencies, MMA is usually a first-line treatment. However, it is highly successful in the treatment of OSA, even in subjects without obvious facial abnormalities [83]. For these Figure 3. Lateral facial radiography following genioglossus advancement. The transparent area indicated by the lower arrow subjects, there is no general agreecorresponds to the mandible segment that has been resected. The ment regarding whether MMA same segment, indicated by the upper arrow, has been advanced, can be a first surgical approach rotated and fixed anteriorly on to the mandible. [78, 80], or whether it should be

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considered only a phase-II surgery, for performance only in patients previously subjected to other (phase I, including palate, hyoid and tongue surgery) surgical treatments with an unsuccessful outcome [84]. Distraction osteogenesis is a technique of bone expansion by means of the application of a device exerting a force progressively disFigure 4. Post-operative radiography following bimaxillary surgery. tracting two close bony segments, In the upper and lower jaws, plates and screws for fixation are which is followed by new tissue evident. An 11-mm advancement of the mandible, as well as of the formation. In OSA, it may be maxillary bones, was carried out in this subject. applied to correct abnormalities of the facial skeleton. In children, before ossification of the midpalatal suture, rapid maxillary expansion may be performed by orthodontists, and is particularly indicated in the case of a narrow palatal arch and posterior crossbite. For 23 weeks, an intra-oral device that exerts forces tending to separate the two halves of the maxilla is applied, and then a device is left in place for the following 612 months [85]. As a result, the floor of the nose is widened, the soft palate is raised and the oral cavity is enlarged so as to better accommodate the tongue, and make it less prone to occluding the airway. The available experience has shown that children often take great advantage from maxillary distraction osteogenesis [86], although they often need adenotonsillectomy as an associated procedure. A similar technique has been described in adults, but usually requires surgical cooperation [87]. Distraction osteogenesis may also be performed in syndromic children with severe facial abnormalities, or in adults who require maxillary or mandibular expansion. It is followed by a lower morbidity than classical surgical procedures, but the duration of treatment and follow-up are considerably longer [88]. The limited experience in adults treated by this technique shows a very high rate of success [89].

Laryngeal surgery
Anatomical or functional abnormalities of the larynx, which can be congenital or acquired, may be a cause of airway obstruction during sleep and failure of supralaryngeal surgical procedures for OSA treatment. Some cases of improvement of OSA following epiglottic surgery have been described in both children and adults [27, 90].

Tracheal surgery
Using tracheostomy, the site of airway occlusion during sleep is bypassed, such that unobstructed breathing can always be restored. Today, it is used mainly during the perioperative period when the most invasive surgical procedures for OSA are planned, particularly in subjects with the most severe forms of OSA, or in emergency situations. As a permanent therapy, it may be used in particular cases at high risk, such as in severe obesity hypoventilation syndrome or multiple system atrophy with stridor, when other treatments are ineffective or cannot be applied [91].

Multilevel surgery
Multilevel surgery consists of the combination of multiple procedures. Most often, UPPP is performed in association with hyoidthyroidpexia, genioglossus advancement or RFVR of the tongue. Multiple mini-invasive procedures may also be combined. It can be performed if the occurrence of airway obstruction during sleep at both a high and low level of the pharynx is suspected, where maxillofacial surgery could represent overtreatment. However, a few cases of

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multilevel surgery including bimaxillary advancement have also been described. According to a recent meta-analysis, the rate of successful treatment of OSA with multilevel surgery is 66%, and is independent of the severity of the disease [92].

Conclusions
Since the earliest OSA surgery in the early 1980s, introduction of new methodologies of preoperative assessment and several new surgical procedures, as well as experience with their application, have improved the capability of appropriately selecting patients for surgical treatment, and chances of success. However, the ability to predict success of treatment remains limited, particularly for phase-I surgery in adults, and most of the present knowledge derives from uncontrolled studies. Among the surgical procedures that have been described, laser-assisted uvulopalatoplasty is no longer recommended. Some techniques have had a limited application (such as some variants of UPPP and hyoid surgery) or were soon abandoned (such as some interventions on the tongue). Minimally invasive techniques, particularly RFVR of the tongue, appear convenient for patients with mild OSA, due to their reasonable effectiveness in these subjects and to the paucity of side-effects. MMA may be recommended in severe OSA, due to its high effectiveness, particularly when some degree of micrognathia is present. Indications for other treatments are less clear. Major problems regarding the literature on the surgical treatment of OSA, pointed out by a Cochrane review, are poor evidence of surgical effectiveness due to the paucity of controlled studies and the limited information regarding long-term effectiveness and important outcomes, such as cardiovascular sequelae and survival [93]. The real challenge for the future is a more scientific and sound demonstration of the efficacy of surgery according to the rules of evidence-based medicine.
UPPER AIRWAY SURGERY FOR OSA

Statement of Interest
None declared.

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