Surgical Intervention of OSA

The Basics

The vast majority of patients with sleep apnea have the obstructive variety called Obstructive Sleep Apnea (OSA). There are a variety of treatments available for OSA.

A few patients may try oral or dental appliances. These devices have the same success rate as surgical intervention. They work best in patients with only mild to moderate OSA.

A nasal air pressure mask called CPAP (continuous positive airway pressure) is the standard treatment for Obstructive Sleep Apnea, with a success rate of 95-98%. Approximately 2-5% of patients who try this therapy experience claustrophobia or do not wish to use CPAP long term. For these individuals, as well as patients who snore but do not have OSA, an oral appliance or surgery may be options. In selected cases, it may be suggested that a patient who is considering treatment with a CPAP mask be evaluated by an ENT (ear, nose, and throat) physician to assure that his or her nose anatomy is adequate. Surgical correction of nasal obstruction may enhance the use of CPAP or improve OSA.

Surgical Options

There are several types of surgery for snoring and sleep apnea, with varying success rates.

The most common types include Tonsillectomy and Adenoidectomy (which are the removal of the tonsils and adenoids).

An excess of soft tissue or enlarged tonsil at the back of the throat may contribute significantly to obstruction of the airway.

Uvulopalatopharyngoplasty (or UPPP for short). The tonsils and adenoids are removed, in addition to carving out some of the hard and soft palate (the back and top of the mouth), removing the uvula (the "little tongue" that hangs down the back of the throat), and removing any other tissues or organs which may be enlarged, blocking the airway. This procedure can also be performed with laser assistance (as opposed the traditional scalpel method). This is called a LAUP. While the UPPP is done in one visit, the LAUP is performed over several visits, usually 3-6 times.

Nasal Septoplasty is used to correct blockages in the nasal passages caused by deformed cartilage from old injuries, polyps, or inflamed tissues. Some patients may have a deviated septum (the cartilage that separates the two nostrils blocks airflow to one side of the nose) which needs correction.

The most intrusive type of surgery is called Mandibular Osteotomy with Geniohyoid and Bimaxillary Advancement. In this case, the lower jaw is broken and advanced, enlarging the airway. Muscles in the chin may be permanently pulled forward to further enlarge the airway. If necessary, surgery may be performed to reduce the size of the base of the tongue.

The most recent advance in surgical techniques is called Somnoplasty. This method uses microwaves (bursts of radio frequencies) to reduce obstruction at the base of the tongue. Somnoplasty may need to be repeated to guarantee results.

Tracheostomy. This is surgical procedure creates a permanent hole in the neck to bypass the obstruction in the upper airway. This is generally performed as a last resort for patients with severe OSA, not responsive to other treatments.

Breathing Disorder During Sleep

Sleep apnea refers to non-breathing episodes during sleep, which may occur as frequently as several hundred times per night. Loud, irregular snoring occurs as the person attempts to breathe at the end of each apnea. Although you may have had a full night's sleep, you may still feel tired during the day.

Sleep apnea is a surprisingly common sleep disorder which can progress in severity and cause serious health problems if not detected and properly treated. The risk of developing OSA increases with advancing age and it is seen most commonly in overweight men.

Sleep apneas can cause serious health problems. With each apnea, oxygen content of the blood decreases causing blood pressure to rise and the heart to slow down. In order to resume breathing, the apnea sufferer will subconsciously arouse to regain muscle tone and open his or her airway. This strategy to breathe means that the individual’s sleep is frequently disrupted, causing daytime sleepiness. Sleep apnea can cause personality changes related to the sleep deprivation and has been associated with hypertension and an increased risk of heart attacks and strokes.

Three Types of Sleep Apnea

Obstructive Sleep Apnea (most common) is caused by a closing of the upper airway (blocking airflow) during sleep. Many factors can contribute to this blockage including nasal obstruction, enlarged tonsils, excessive tissue in the back of the throat and an enlarged tongue. During sleep, the airway muscles relax which contributes to this blockage. A person with OSA continues to try to breathe, but cannot pass air through the obstructed upper airway.

Central Sleep Apnea occurs when a person no longer tries to breathe. There seems to be no signal from the brain to keep breathing.

Mixed Sleep Apnea refers to a combination of central and obstructive apnea.

Diagnosis and Treatment

The diagnosis of OSA may be suspected, based upon a suggestive history and certain characteristics seen on physical examination by your physician. Proper diagnosis, however, can only be made by special monitoring of the individual’s sleep, by a polysomnogram.

Treatment for snoring and sleep apnea depends on what type of apnea you have and how serious it is. This information can only be obtained through a sleep study (polysomnogram or PSG). Based on the results of the sleep test, the physician can prescribe the appropriate treatment. This can be any of the following:

Behavior changes such as losing weight, avoiding alcohol and exercising regularly. Proper Sleep Hygiene is crucial. A Continuous Positive Airway Pressure device (CPAP) that splints the airway open so one breathes steadily and normally. The flow of the air pushes on the collapsed tissues and muscles, leaving the airway open. An oral device worn in the mouth to change the position of the jaw and tongue. This helps open the airway. Surgery to increase the size of the upper airway (where obstruction occurs).

Air Pressure Devices

An air pressure device has a soft plastic (silicone) mask that fits around the nose. Wearing this mask may feel odd at first, but most people get used to it very quickly with some help from our Sleep Lab staff.

The most commonly used type of air pressure device is CPAP (Continuous Positive Airway Pressure). It literally blows air through the nasal passages and throat, keeping the airway open. Snoring is prevented. Breathing is maintained. This is the preferred treatment for most patients with significant OSA.

Snoring

People with sleep apnea often snore very loudly. But not everyone who snores has sleep apnea. If one snores, and then stops breathing, then makes snorting, gasping or choking sounds, one may have sleep apnea.

Find out what the snoring patterns are. Ask one’s bed partner to watch and take notes. If a bed partner is not available, set up a tape recorder.

These hints may quiet or lessen snoring:

Sleep in a lateral position. Sleeping on your back may increase snoring. Tissues in the throat block the airway causing snoring. These tissues are more likely to collapse downward when supine. To avoid this, sew a pocket or pin a sock on the back of a pajama shirt. Place a tennis ball in the sock. This will prevent rolling supine.

Clear your nose. Allergies and colds can block the nasal passages, increasing snoring and sleep apnea. Consider nasal sprays and humidity.

Avoid alcohol. This further relaxes the muscles in the throat, increasing the likelihood of collapse and airway blockage. When this happens, snoring and sleep apnea are worse.

Lose weight. Increased body mass leads to larger tissues in the nose and throat, increasing the chance of blocked airways, leading to snoring and sleep apnea. Exercise regularly.

Snoring may not be a problem for the patient, but it can be a problem for the bed partner, others in the home and sometimes even the neighbors!

OBSTRUCTIVE SLEEP APNEA

  • Sleep Apnea Screening
  • Surgical Intervention for Obstructive Sleep Apnea
  • More on OSA and Snoring

What Is It?

Sleep apnea is a serious potentially life threatening condition.

  • OSA is common (4% men / 2% women), about the same incidence as asthma.
  • Characterized by repeated episodes of upper airway obstruction during sleep.
  • Almost always associated with snoring, although not everyone who snores has OSA.
  • Patients may experience choking. Bed partner may notice pauses in breathing (apneas).
  • Frequent interruptions of sleep lead to excessive daytime sleepiness.
  • Early recognition and treatment are important as OSA is associated with heart attacks, hypertension, and stroke.

Who Gets It?

  • More common in men
  • Increased incidence with age
  • People who snore
  • People who are overweight
  • Higher incidence in people with high blood pressure

How Is It Diagnosed?

  • First need to suspect it; sleeping partners/spouses notice snoring with spells of choking and pauses in breathing during sleep.
  • Test called a Polysomnogram that records a variety of body functions during sleep, such as:
    • Electrical activity of the brain
    • Eye movements
    • Muscle activity
    • Heart rate
    • Respiratory effort
    • Blood oxygen levels
  • Used to diagnose OSA and determine it’s severity, frequently can initiate therapy during the test

How Is It Treated?

  • Tailored to individual
  • Behavioral - weight loss, avoid sedatives and alcohol, practice good sleep hygiene Physical or mechanical - nasal Continuous Positive Airway Pressure (CPAP)
  • Dental appliances, particularly if OSA is mild
  • Surgery:
    • Tonsillectomy and adenoidectomy work well in children
    • Correction of nasal obstruction
    • Procedures to advance the jaw and tongue forward
    • UPPP - often combined with above; only approximately 50% success rate when done alone
    • Somnoplasty
    • Tracheostomy - only for severe life-threatening apnea
  • Research - How OSA affects and interacts with other medical conditions