AMERICAN SLEEP APNEA ASSOCIATION

6856 Eastern Avenue, NW Ste. 203

Washington, DC 20012
(202) 293-3650

Overview of Surgical Options for OSA

While continuous positive airway pressure (CPAP) is the first line of treatment for sleep
apnea, patient compliance represents a clear problem. Studies have shown that even in
compliant patients, the actual usage of CPAP is only approximately 50% of the time.
Patients often complain of difficulty in being able to wear a tight mask throughout the
night and dealing with the high pressure of air blown into their nose. It is for these
reasons that surgery for sleep apnea can be a feasible alternative. While there are many
surgical options, surgery should be tailored to the area of obstruction in each particular
patient. The sites of obstruction could be anywhere in the upper respiratory tract
including the nose, tongue, and throat. Below are the most common and effective
surgical methods to address these potential sites of obstruction.

Nasal Surgery
Both daytime nasal obstruction and nocturnal nasal congestion have been shown as risk
factors for sleep-disordered breathing. Therefore, the treatment of nasal obstruction plays
an important role in sleep apnea surgery. Three anatomic areas of the nose that may
contribute to obstruction are the septum, the turbinates, and the nasal valve. The most
common nasal surgical procedure consists of septoplasty and turbinate reduction. This is
an outpatient procedure that is very well tolerated. It consists of straightening out the
septum and reducing the size of the turbinates. This procedure creates more room in the
nose and allows air to pass smoothly and without effort. For some patients, there is also
nasal valve collapse. This is due to weakness of the lower nasal cartilages that hold open
the nostrils. For patients who have this issue, the deviated cartilage that is removed from
the septum can be strategically placed to strengthen the valve and prevent collapse.

Uvulopalatopharyngoplasty
Uvulopalatopharyngoplasty has been the most common sleep apnea surgical procedure
performed during the past 25 years. This procedure was developed to remove redundant
tissue from the soft palate and pharynx. The tonsils are also removed if present. After
removing the excess tissue, sutures are placed to keep the area widely open and prevent
collapse. This area of the upper airway is referred as the oropharynx, and is a common
site of obstruction in the majority of patients who suffer from sleep apnea. This surgery
requires an overnight stay in the hospital, as the recovery can be painful for up to one
week. Patients who suffer from snoring gain a great deal improvement from this
procedure as snoring is often due to the reverberation of the soft palate with the back wall
of the pharynx.
 Soft Palate Implants (The Pillar™ Procedure)
The Pillar™ Procedure is a minimally invasive approach that can help with snoring and
mild cases of sleep apnea. It involves the placement of three polyester rods into the soft
palate. The rods initiate an inflammatory response of the surrounding soft tissues that
results in a slight stiffening of the soft palate. The stiffer soft palate is less likely to make
contact with the back wall of the pharynx during deep stages of sleep as the muscles
relax; snoring and apnea are subsequently reduced. This procedure can be done under
local anesthesia in the clinic with the patient awake.

Hyoid Advancement
The hyoid bone is a small bone in the neck where the muscles of the tongue base and
pharynx attach. Patients with sleep apnea often have a large tongue base. During the
deep stages of sleep, normal muscle tone is relaxed, and the base of tongue falls back and
can make contact with the back wall of the pharynx resulting in obstruction. Through a
very minimally invasive procedure, the hyoid bone is surgically repositioned anteriorly
by placing a suture around it and suspending it to the front of the jaw bone. This results in
an expansion of the airway and prevents collapse. The procedure is usually performed
with two small incisions in the neck and is completed in less than one hour. Patients go
home immediately after surgery and pain is minimal. Success from this procedure has
been outstanding and is becoming a valuable tool in the surgeon’s armamentarium.

Genioglossus Advancement
This procedure involves advancing one of the main tongue muscles, the genioglossus
muscle, anteriorly; thereby limiting the posterior displacement during sleep. The
genioglossus advancement procedure consists of making a rectangular cut in the jaw bone
where the genioglossus muscle attaches. The piece of bone is then moved forward with
the muscle attached. The bone is fixed into place with a small titanium plate to prevent
retraction back into the floor of the mouth. This procedure addresses the same sites of
potential obstruction as the hyoid advancement, and numerous studies have shown a high
success rate. This procedure, however, requires an overnight stay in the hospital, as it is
more invasive.
Tongue Base Reduction
As discussed previously, the base of tongue is a common site of obstruction in patients
who suffer from OSA. In addition the advancement procedures, reducing the amount of
tissue from the tongue base through a variety of methods is an effective surgical method
to reduce apnea. One method is through the application of radiofrequency waves. A
surge of energy is introduced to the tissue that results in shrinkage of the tissue. The
radiofrequency waves are directed to specific sites in the tongue base without causing
surrounding tissue damage. While the procedure is minimally invasive, and can
sometimes be done with the patient awake in the clinic, several treatments are necessary.
Another method to reduce the tongue base is through direct excision. In this procedure,
also known as a midline glossectomy, the tongue base tissue is removed by electrocautery
or coblation. This is accomplished under general anesthesia in the operating room and is
also tolerated with very little pain. Due to the small, but real risk of airway compromise,
patients are observed overnight in the hospital. Studies have shown that all methods of
tongue base reduction can be effective when properly employed.
 Maxillomandibular Advancement
Abnormality of the maxillofacial skeleton is a well-recognized risk factor of obstructive
sleep apnea. Sleep apnea patients usually have small, narrow jaws that result in
diminished airway dimension, which leads to nocturnal obstruction. Maxillomandibular
advancement achieves enlargement of the entire upper airway through expansion of the
skeletal framework that encircle the airway. The procedure consists of mobilizing the
upper and lower jaw bones, and advancing then up to 10-12mm. The jaw bones are
stabilized with titanium plates in the advanced position. This procedure is technically
very challenging as the bone cuts need to be precise, and the positioning of the teeth to
match correctly after the advancement is critical. Patients have to have their teeth wired
shut for several weeks while the bones heal. While the surgery can be painful and require
a several night hospital stay, the long term success rates approach 90%. Very few
surgeons and medical centers perform this procedure frequently due to the increased
surgical risks and potential for complications.

Tracheostomy
Tracheostomy is a technique that creates a passageway for air to get to the lungs directly
from the trachea in the neck. This will bypass any potential sites of obstruction from the
upper airway. Permanent tracheostomy as a long-term treatment of obstructive sleep
apnea remains an option in morbidly obese patients with obesity hypoventilation
syndrome or in patients with significant craniofacial anomaly who have failed all other
forms of non-surgical and surgical treatments. Though it may seem excessive, it is an
extremely effective surgical option reserved for the very sick patient.

SUMMARY
There are many surgical options for the treatment of sleep apnea for patients who can not
tolerate CPAP therapy. Because the airway pattern and the severity of obstruction vary
greatly between individuals, the surgical regimen must be catered to that particular
individual. Often it takes a combination of procedures to achieve success. A logical
step-wise approach much be taken when a patient seeks surgery, and it is a requisite that
the patient find a surgeon who understands both the pathophysiology of sleep apnea and
the anatomy of the upper respiratory tract to ensure the best chance of success.

This document prepared in consultation with Ravi S. Swamy, MD, MPH