Surgical Treatment of Obstructive Sleep Apnea

Surgical Treatment of Obstructive Sleep Apnea

Introduction

Obstructive Sleep Apnea (OSA) is a breathing disorder that occurs during sleep. The muscular relaxation that occurs in the deepest stages of sleep can permit the soft palate and tongue to drop backwards causing a temporary closing of the breathing passage. The dynamic intermittent obstruction to breathing can sometimes be seen at the entrance to the voice box in contrast to the relatively fixed blockage seen within the nose.

The nocturnal obstruction to breathing can be complete or partial. A total blockage to breathing with no air movement for 10 seconds or more is called an apnea.  OSA patients can have apneic events which last 45 seconds or even longer and happen multiple times during the night. As you would imagine, when breathing ceases for long periods of time, oxygen levels in the blood will drop. The lowest oxygen saturation (LSAT) recorded during sleep is one feature used as an indicator of disease severity. Partial blockages to breathing that reduce airflow below normal by more than one half for more than 10 seconds are called hypopneas. The average number of apneas and hypopneas per hour is called the respiratory disturbance index (RDI).

The repetitive night-time blockage to breathing interferes with the normal physiology of sleep. Normal sleep architecture is seen as characteristic EEG (electroencephalogram) waveforms and durations at the different levels of sleep.  With OSA the normal EEG architecture is altered such that the deepest and most restful levels of sleep are minimized or abolished. How does this happen? While in the depth of sleep, airway occlusion occurs due to poor muscular tone. In response to an obstructive event, the brain partly awakens which is called an arousal. During an arousal muscular tone is increased and the obstruction to breathing is relieved.  Multiple arousals from deep sleep occur all night long in response to the repetitive apneic and hypopneic events. Perhaps this is a natural defense mechanism which prevents suffocation, but at the expense of high quality sleep. Repetitive nocturnal obstruction to breathing results in poor quality sleep with visible symptoms of sleep deprivation.

Many factors may predispose to OSA. The character of the skeletal and soft tissues supporting the throat are important. A small lower jaw, large tongue, intrusive tonsils, enlarged adenoids and long floppy soft palate can be contributing features. Male gender, excess weight or obesity and aging are typical risk factors for OSA. The use of alcohol, sedatives, tranquilizers or antihistamines around bedtime can precipitate snoring and OSA.

The diagnosis of OSA is made by a test commonly called a sleep study or polysomnogram. This is preferably done in a  facility accredited by the American Sleep Disorders Association and requires an overnight stay. The study measures multiple body functions which includes your efforts at breathing, oxygen levels, heart rhythms and EEG while you are asleep.

OSA is often treated by non-surgical methods. The standard non-surgical treatment is called continuous positive airway pressure (CPAP). Through a mask, the CPAP device pushes room air into the breathing passage which temporarily prevents the collapse of the airway. CPAP is not a cure, but a support measure. As such, when CPAP is not used nocturnal obstruction to breathing will occur again.

Surgery  can successfully treat obstructive sleep apnea. Hence, one can avoid or eliminate the need for CPAP usage and provide satisfaction for those people who can not tolerate the treatment. The basic surgical strategy is to open the one or more sites of obstruction to breathing typically at the nose, palate or tongue base. Some of the procedures are well known such as removal of the tonsils, trimming of the soft palate or straightening the crooked septum. Other less known techniques enlarge the breathing passage behind the tongue. This may entail operation directly on the tongue tendons or indirectly on the jaw. The type of OSA surgery that you are offered is designed specifically for your particular problem since the blockage to breathing does not always occur in the same location. 

Various combinations of procedures are sometimes required in order to open the multiple areas of blockage.  Snoring can also be eliminated allowing restful sleep for spouses and other family members.

Why treat?

If after a formal sleep study, the diagnosis is made of Obstructive Sleep Apnea, there are both subjective personal reasons and objective medical reasons to seriously consider treatment. Repetitive obstruction to breathing during sleep can produce blood oxygen levels dramatically below normal with resultant effects on the heart and brain. Obstruction to breathing triggers a reduction in the depth of sleep so as to improve muscle tone and relieve the blockage to breathing. The result is a poor quality of sleep and impaired “quality of life.” Chronic deprivation of quality sleep results in severe daytime sleepiness and fatigue with deficits in thinking, impaired memory and communication.  It also can result in moodiness, irritability and depression and is statistically linked to a dramatic increased risk of automobile and truck accidents.

OSA is associated with and may promote severe life threatening diseases. Several reports suggest a slight decrease in life span when OSA is not adequately treated. OSA is very commonly associated with high blood pressure and has an increased risk of heart attack, irregular heart beats and stroke. The natural evolution of untreated severe OSA is often congestive heart and respiratory failure even in young patients. It seems intuitive that undiagnosed or untreated OSA appears to be associated with a dramatically higher cost of medical care. Fortunately OSA can be treated  by medical and, or, surgical methods and will improve both subjective and objective deficits.

Non-Surgical Therapies

The standard non-surgical treatment of Obstuctive Sleep Apnea  is called continuous positive airway pressure (CPAP). Through a mask, the CPAP device delivers room air under pressure into the breathing passage. The pressurized air  prevents the collapse of the upper airway so that inspiration and expiration can occur without obstruction.

Lack of long-term compliance is the major problem with CPAP treatment for OSA. There can be many issues with CPAP which prevent its use, limit its use or make side effects so intolerable that it is not used.  CPAP pressures can not always be adequately adjusted to treat OSA. Some patients who frequently travel find it inconvenient and difficult to carry the CPAP device from place to place. The mask may cause local problems like skin irritation or air leakage into the eyes or from the mouth. A sense of suffocation, difficulty with exhaling, or nasal congestion are common complaints with CPAP use. Since CPAP therapy is not a cure, but a support measure, in my experience, patients can dread the likely need for lifetime use of the appliance. Fortunately after surgical intervention there is often no issue of compliance with treatment other than weight stabilization and prudent use of sedatives.

There are a host of other non-surgical approaches for treating OSA and some of them will be discussed. Weight loss for obese patients with OSA should be encouraged and recommended, but is not easily achieved in the short-term and more difficult to maintain in the long-term. Avoidance of alcohol and sedatives is common sense because both produce muscular relaxation and may predispose to or exacerbate OSA.  Jaw advancement and tongue retaining appliances pull the airway open by thrusting the mandible or tongue forward. Only a small fraction of patients are “cured” of OSA using these appliances. With long-term use some will develop jaw joint dysfunction (TMJ) or unplanned movement of teeth with potential malalignment of the bite. Since OSA is often dependent on body position, avoidance of sleeping on one’s back may be helpful for mild disease.

If non-surgical remedies are unable to resolve the OSA then the surgical strategy should be considered. The surgical strategy is also to prevent the tongue and palate from falling backwards by advancing, shortening or stiffening these structures. This may involve surgery at that particular site or indirectly on the adjacent jaws or neck.

Surgical Techniques

Nasal, Septal and Adenoid Surgery

Nasal, Septal and Adenoid surgeries are sometimes performed in order to open the nasal breathing passages and permit easier breathing.  The constant nasal airway obstruction is typically in contrast to the dynamic collapse seen at the level of the palate or tongue, but needs to be considered in every case of Obstructive Sleep Apnea airway reconstruction. Indeed, more than half of the OSA patient population will have findings of nasal airway compromise.

Reconstruction of the nose is called rhinoplasty and may be performed to enhance appearance or for functional reasons. The quality of the tissue around the nostrils or deeper in the nose can cause restricted breathing. Weak or malpositioned cartilages around the nostrils can impede nasal breathing as will a droopy nasal tip or excessively narrow nostrils. A “nose job” directed at improving breathing will also usually enhance appearance.

Adverse cosmetic and functional outcomes can sometimes be seen after rhinoplasty. Real and perceived cosmetic deformities are possible. The best result is the nose that looks natural for a given face.

The nasal turbinates are horizontal ridges within the nose. These may become chronically enlarged usually as a result of allergies. Reduction in the size of the turbinates will improve nasal air flow.

The nasal septum divides the nose into right and left nasal passages. A septal deviation is an alteration of the relatively straight and midline position of the septum.  If the septum is crooked, it may cause blockage of the nasal breathing passage. It can be straightened in order to improve breathing and is called a septoplasty. 

An enlarged adenoid may occasionally interfere with breathing. The adenoid is located in the very back of the nasal cavity above the soft palate. An adenoidectomy removes this excess tissue to allow for unrestricted airflow through the nasal passages and upper throat. Although this is most commonly performed in children, it may be indicated in teenagers or young adults.

UPPP & Tonsillectomy

The uvulo-palato-pharyngoplasty (UPPP) and tonsillectomy are often performed as a part of Obstructive Sleep Apnea surgery. The UPPP procedure shortens and stiffens the soft palate by partial removal of the uvula and reduction of the edge of the soft palate. Since there may be other sites of restriction to breathing, such as the tongue base, the UPPP and tonsillectomy may not resolve the OSA.  Most patients who snore, but do not have apnea should enjoy a dramatic decrease in loudness of snoring after UPPP.     

Complications of the UPPP procedure are not common, but merit discussion. The palate is a valve which separates the nose from the mouth. This valve is like any other in that it may be broken and stuck in an open or closed position.  A palate that no longer completely seals the nose from the mouth has the sound of excess nasal tones and possible leakage of liquids out of the nose.  On the other hand, rare instances of severe scarring of the palate could potentially worsen the OSA and make speech unusually non-nasal sounding. Care is taken to avoid either complication by judicious planning and careful technical execution of the procedure.  Some patients do note a foreign body feeling when they swallow after having had a UPPP and is due to scar formation. 

The tonsillectomy can be an important component of surgery for OSA, especially if the tonsils are at all enlarged. The removal of redundant tissue by tonsillectomy increases the caliber of the throat thereby reducing blockage to breathing. Since the quality and quantity of tissue of the throat changes after tonsillectomy there can be a subtle alteration in voice quality. In a mature adult, pain following tonsillectomy can be unpleasant, but is reasonably well controlled with prescription medication.  The UPPP and tonsillectomy remain a very important part of surgery to expand the upper breathing passage for treatment of OSA.

Genio-Glossus Advancement

The Genio-Glossus Advancement (GGA) is a procedure which was developed specifically for the treatment of Obstructive Sleep Apnea.  Like all surgery for this condition, the operation is designed to open the upper breathing passage. The concept is that a muscle, such as the tongue, will be displaced as it’s tendon  is moved or tightened. An analogy is that  in order to prevent a pair of  pants from dropping lower one would tighten ones’ suspenders. The GGA procedure tightens the front tongue tendon; thereby, reducing the degree of tongue displacement into the throat.

The procedure is done through the mouth through an incision below the gum tissue in front of the lower front teeth. After creating a small rectangular bone window, the tendons that attach the front of the tongue to the jaw are pulled forward on a small bone fragment.  This produces a larger space between the back of the tongue and the throat thereby creating a wider airway. Complications resulting from this procedure are very uncommon. There is minimal if any alteration in facial appearance and my patients have not complained about this issue. This operation is often performed in tandem with at least one other procedure such as the UPPP or hyoid suspension.

Hyoid Suspension

The Hyoid Suspension is a procedure which was developed specifically for the treatment of Obstructive Sleep Apnea. The operation advances the tongue base and epiglottis forward, thereby,  opening the breathing passage at this level.  The hyoid bone is located just above the thyroid cartilage  (” the Adam’s apple”).  The procedure is done through a small horizontal incision in a convenient skin crease in the upper neck and takes under an hour to perform. By detaching two tendons on the upper surface of the hyoid bone and some of the muscle on the lower surface, the hyoid can be advanced over the thyroid cartilage and secured in position.  Since the vocal cords are not manipulated, the voice should remain unimpaired.

Maxillo-mandibular Advancement

Maxillo-mandibular Advancement (MMA) or double jaw advancement is a procedure whereby the upper and lower jaws are surgically moved forward (Lefort 1 osteotomy of the maxilla & saggital split advancement of the mandible).  The concept is that as the bones are surgically advanced the soft tissues of the tongue and palate are also moved forward, again opening the upper airway.  The usual movement is about a half an inch.  Since the upper and lower teeth are moved the same amount, the bite would be similar before and after operation. 

The MMA will always alter and often enhance appearance, but is not disfiguring.  The operation is accomplished through the mouth.  The jaws may be briefly wired closed following the operation.  The procedure is technically involved with the potential for complications as in any surgical procedure, but most patients recover remarkably well from this surgery. 

For some individuals, the MMA is the only technique that can adequately create the necessary air passageway that can resolve the OSA condition with finality.

Tracheotomy

A Tracheotomy is one of the oldest, most shunned, and least understood procedures for Obstructive Sleep Apnea.  The concept with this procedure is that any area of blockage to breathing, from the nose to the voice-box, is bypassed by a hole placed into the windpipe. The hole in the trachea is called a stoma. The stoma must be maintained both by daily cleaning and by insertion of a tube.  The tracheotomy tube must be kept exquisitely clean; otherwise, painful infections of the stoma will occur, or the tube and/or windpipe could become blocked with secretions. 

A tracheotomy does not mean that a patient would not be able to talk. If the tube would be plugged by a finger, then air from the lungs would pass through the voice box allowing one to talk by mouth. When the tube would be unplugged, or open, then air from the lungs would largely bypass the voice box not allowing one to talk by mouth. Some patients plug the tube closed during the day to allow normal conversation by mouth, but release the plug for night-time use when speech is not required, and OSA needs treatment. A special valve could be placed on top of the tracheotomy tube to allow “hands free” speech. Most patients eat without difficulty despite the tracheotomy tube.

Just because a tracheotomy has been placed, it does not necessarily mean that the tracheotomy would need to be permanent. It might be possible to perform some of the operations outlined in this web site and eventually have the tube removed. For example, when OSA is severe and CPAP is not tolerated or ineffective or cardio-pulmonary failure has developed then a tracheotomy may be the initial treatment of choice. This is done to reverse the severe sleep deprivation, depression and cognitive deficits of OSA and to stabilize or reverse the cardio-pulmonary problems as a result of chronic OSA. A month or two later a sequence of procedures can be initiated as indicated.

After the indicated procedures have been performed a sleep study is done with the tracheotomy tube capped shut. If the sleep study showed resolution of the OSA then formal plans could be made to remove the tracheotomy tube and allow the stoma to be closed. Obviously, the likelihood of being able to safely remove the tracheotomy tube because of OSA resolution is dependent on multiple factors including: patient motivation/ interest, anatomical and physiological constraints, disease severity and level of physician expertise in dealing with OSA and its surgical management.

Somnoplasty Treatment

The Somnoplasty procedure is the most recent addition of the treatment options for Obstructive Sleep Apnea. This technique uses well established technology with application to OSA. A needle probe is inserted into the tissue of the nose, palate or tongue as indicated by the site of obstruction to breathing. A small electrical current then heats the tissue, but no visible change occurs. During the following six to eight weeks the submerged wound undergoes healing, contraction and stiffening.

The intended result is relief of nasal obstruction when used to shrink the nasal turbinates, diminished snoring when used to reduce the soft palate or elimination of OSA when used for tongue reduction. The main advantages of this treatment are minimal pain and treatment in the office setting. At present, the disadvantages of Somnoplasty treatment for OSA are the need for multiple treatment sessions, overall limited clinical experience with the technique and difficulty with insurance coverage for the procedure.

Choosing Surgeon

Choosing the best surgeon for the treatment of your obstructive sleep apnea is a very important decision. The wrong choice of surgeon may lessen the chances of being free of OSA. The type of surgery that is proposed to you will depend in part on the physician’s knowledge of this problem. Not every practitioner has the skills or technical expertise in both hard and soft tissue reconstructive surgery to be able to perform all of the procedures described in this post.

The ability to use the full array of current surgical techniques allows the surgeon flexibility to tailor a treatment plan to fit the patients’ needs rather than adapting a patient to a standard surgical plan. This versatility is difficult to find with most physicians that are not formally trained in oral & maxillofacial surgery, otolaryngology head & neck surgery and fellowship trained in facial reconstructive surgery.

Indeed, the surgeon’s reputation with treating obstructive sleep apnea should be able to be verified by former patients, nurses and other physicians. The patient should have complete confidence in the surgeons abilities and commitment to solving the OSA problem before beginning any course of surgical treatment.

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