Sleep surgery is a range of surgical procedures to treat sleep-related breathing disorders (sleep-disordered breathing), especially obstructive sleep apnea (OSA). The spectrum of sleep-related breathing disorders also includes primary snoring (non apneic snoring), upper airway resistance syndrome, and obesity hypoventilation syndrome. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.
Background
Obstructive sleep apnea (OSA) is defined as either cessation of breathing (apnea) for 10 seconds, or a decrease in normal breathing (hypopnea) with an associated desaturation in oxygen and arousal during sleep that lasts at least 10 seconds. In adults, it is typical to have up to 4.9 events per hour. In OSA, affected individuals are categorized based on how many apneas or hypopneas (apnea-hypopnea index or AHI) or events they have per hour.
Normal: <5 events per hour Mild: 5 to <15 events per hour Moderate: 15 to 30 events per hour Severe: >30 events per hour The prevalence of OSA (5 or more events/hr) is about 9% for women and 24% for men. Among sleepy patients in this group, 2% of women and 4% of men meet criteria for obstructive sleep apnea syndrome (OSAS). Those who snore habitually are more likely to have an AHI of 15 or more. Non surgical treatments for sleep disordered breathing include continuous positive airway pressure (CPAP), mandibular advancement splints, and tongue retaining devices. Sleep surgery aims to reduce daytime sleepiness, increase quality of life, and improve parameters recorded on polysomnography. In general, all the procedures achieve this by removing or preventing obstruction of the upper airway during sleep.
Choice of procedure Most people with OSA have multiple points of obstruction in their airway and therefore require multilevel sleep surgery in order to maximize the efficacy of treatment. Multilevel sleep surgery achieves a 60.3% AHI reduction. This reduction in sleep apnea severity via surgical means compares well against the AHI reduction for best case CPAP patients where an overall AHI reduction of 66% was achieved. Even single level surgical intervention in sleep apnea, which demonstrates a lesser degree of AHI reduction, shows a 31% survival benefit when compared against those using CPAP as therapy.
Tonsillectomy and/or adenoidectomy Children with OSA typically have enlarged tonsils and adenoid tissue because the lymphoid tissue grows fast during young age. Surgical removal of enlarged tonsils (tonsillectomy) and the adenoid (adenoidectomy) or both (adenotonsillectomy) are first line treatment among children with OSA. Those less likely to benefit from adenotonsillectomy are obese children and those with other medical problems, such as Down syndrome. Sometimes a milder surgical procedure called tonsillotomy is used to remove the protruding tonsillar tissue instead of removing the tonsils entirely, a method associated with less pain and lower risk of postoperative hemorrhage. Some adults with large tonsils may be candidates for having their tonsils and/or adenoids removed either alone or in combination with other procedures, such as uvulopalatopharyngoplasty (UPPP) or nasal surgery.
Uvulopalatopharyngoplasty (UPPP)
The procedure most commonly performed for sleep apnea is the uvulopalatopharyngoplasty (UPPP). This involves removal of the tonsils if still present, and a subsequent palatal procedure. The tonsil pillars are often sutured closed—and the uvula is either trimmed, cut, folded, reshaped, or sutured to the soft palate. Studies have shown that treatment effect of UPPP with tonsillectomy increases with tonsil size. Some procedures attempt to widen the airway by removing tissues in the back of the throat, including the uvula and pharynx. These surgeries are quite invasive, however, and there are risks of adverse side effects. The most dangerous risk is that enough scar tissue could form within the throat as a result of the incisions to make the airway more narrow than it was prior to surgery, diminishing the airspace in the velopharynx. Scarring is an individual trait, so it is difficult for a surgeon to predict how much a person might be predisposed to scarring. Currently, the American Medical Association does not approve of the use of lasers to perform operations on the pharynx or uvula.
Pillar procedure The pillar procedure is a minimally invasive treatment for snoring and obstructive sleep apnea. In the United States, this procedure was approved by the FDA in 2004. During this procedure, three to six+ polyethylene terephthalate strips are inserted into the soft palate, using a modified syringe and local anesthetic. While the procedure was initially approved for the insertion of three "pillars" into the soft palate, it was found that there was a significant dosage response to more pillars, with appropriate candidates. As a result of this outpatient operation, which typically lasts no more than 30 minutes, the soft palate is more rigid, possibly reducing instances of sleep apnea and snoring. This procedure addresses one of the most common causes of snoring and sleep apnea—vibration or collapse of the soft palate (the soft part of the roof of the mouth). If there are other factors contributing to snoring or sleep apnea, such as conditions of the nasal airway or an enlarged tongue, it will likely need to be combined with other treatments to be more effective.
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