Surgical Procedures for Obstructive Sleep Apnea
The primary surgical procedure for obstructive sleep apnea is uvulopalatopharyngoplasty (UPPP), which aims to enlarge the retropalatal airway by trimming and reorienting the posterior and anterior lateral pharyngeal pillars, and by excising the uvula and the posterior soft palate. 1
Common Surgical Procedures for OSA by Anatomical Site
Upper Airway Bypass Procedure
- Tracheotomy - can eliminate OSA but does not appropriately treat central hypoventilation syndromes 1
Nasal Procedures
- Septoplasty for nasal septal deviation 2
- Functional rhinoplasty 1
- Nasal valve surgery 1
- Turbinate reduction for marked turbinate hypertrophy 2
- Nasal polypectomy 1
- Endoscopic procedures 1
Oral, Oropharyngeal, and Nasopharyngeal Procedures
- Uvulopalatopharyngoplasty (UPPP) and variations - the most common surgical procedure for OSA 1, 3
- Palatal advancement pharyngoplasty 1
- Tonsillectomy and/or adenoidectomy 1
- Excision of tori mandibularis 1
- Palatal implants 1
- Laser-assisted uvulopalatoplasty (LAUP) - an office-based surgical procedure that progressively shortens and tightens the uvula and palate through carbon dioxide laser incisions 1, 4
Hypopharyngeal Procedures
- Tongue Reduction procedures:
- Tongue Advancement/Stabilization procedures:
Laryngeal Procedures
Global Airway Procedures
- Maxillomandibular advancement - can improve PSG parameters comparable to CPAP in the majority of patients 1, 6
- Bariatric surgery 1
Multilevel Surgery (MLS)
- Combines procedures at different anatomical levels to address multiple sites of obstruction 1
- Success rate varies between 22.7% to 78% (mean 60.9%) 1
- May be considered as a salvage procedure for sleep apnea patients in whom CPAP and other conservative therapies have failed 2
Efficacy and Patient Selection
- UPPP has a reported success rate of <50% in unselected populations of mild to moderate sleep apnea 1
- Success rates for isolated soft palate procedures are generally poor (approximately 50% success rate) and even lower in patients with multi-level obstruction 2, 7
- Patients with retropalatal and retrolingual collapse have only a 5% success rate with isolated palatal procedures 2, 6
- UPPP cannot be recommended except in carefully selected patients with obstruction limited to the oropharyngeal area (Grade C recommendation) 1
- LAUP has not demonstrated any significant effect on OSA severity, symptoms, or quality of life domains and is therefore not recommended (Grade B recommendation) 1
- Surgical success rates for tongue-based procedures decrease with increasing BMI and AHI 5
Complications and Side Effects
- Serious life-threatening complications of UPPP include intubation difficulties, bleeding, and acute upper airway obstruction (1.5% incidence, 0.2% mortality rate) 1
- Long-term side effects persist after UPPP in 58% of patients, including velopharyngeal insufficiency, dry throat, abnormal swallowing, globus sensation, and voice changes 1
- Having undergone UPPP has been proposed as a risk factor for CPAP non-compliance 1
- Complications of tongue procedures may include temporary dysphagia, odynophagia, and floor of mouth infections 5
Evaluation and Follow-up
- The diagnosis of OSA should be established prior to surgery and the severity determined by objective testing 1
- Anatomical examination is necessary to identify possible surgical sites 1
- Post-treatment follow-up should include polysomnography to objectively assess improvement 5
- Patients should be counseled on surgical options, likelihood of success, goals of treatment, risks and benefits, possible side effects, and alternative treatments 1