In our most recent blog, we were talking about positive airway pressure (PAP) therapy, which usually takes the for of continuous positive airway pressure or CPAP. Though PAP is the "gold standard" and the most effective therapy for obstructive sleep apnea (OSA), we noted that many patients have difficulty maintaining its use over the long term. We also discussed some of the techniques a good sleep center will utilize to improve the long term compliance to CPAP. In this blog, I wanted to review some other options in the treatment of OSA, particularly surgical treatments.
In most children, the primary treatment for OSA is surgery to remove the tonsils and adenoid tissue. This generally improves the sleep apnea and returns their sleep to normal. Unfortunately with the rapidly expanding epidemic (pun intended) of childhood obesity, sleep centers are beginning to see more "adult-like" sleep apnea, where this surgery alone may not help.
Before outlining a few of the available surgical options, I think a few introductory remarks are necessary. Surgery for OSA is typically performed by otolaryngologists (better known as ear, nose, and throat or ENT doctors). The goal of the surgery is to eliminate the sites of obstruction that occur in the different locations of the nose and throat, that are the cause of sleep apnea (please refer to our original OSA blog). These areas are collectively known as the pharynx, and include the naso-, oro-, and hypopharynx. Surgical procedures for OSA are unpredictable and generally less effective than PAP. Surgical success depends on appropriately selecting patients, the type of procedure performed, and the experience of the surgeon.
The surgeries are typically broken down into phase 1 and phase 2 surgeries. Phase 1 surgeries are more routine and much less intensive. The phase 2 surgeries are primarily performed in very specialized centers, by physicians specifically trained in surgically treating OSA. Under most circumstances, the phase 2 surgeries are not performed until the patient has a failed phase 1 surgery attempt.
The most widely used surgical treatment for OSA is called uvulopalatopharyngoplasty (UPPP for short) and the related uvulopalatal flap (UPF). In these techniques, the uvula, (the piece of tissue that hangs down to the back of the throat) and other tissue surrounding it are trimmed and/or removed. These procedures may also include the removal of the tonsils and adenoids. This opens up the airway and gives extra space to help avoid the tissue obstruction that causes OSA. There is also a similar office-based procedure, using a laser, called laser-assisted uvuloplasty that performs the same removal of tissue, progressively on a number of office visits.
A number of other surgical techniques try to address the other areas of obstruction- the nose and tongue. Nasal reconstruction targets extra or distorted tissue in the nose that blocks the flow of air. The advantage of the nasal reconstructive surgery is that, even though it does little for treating sleep apnea itself, it might make a person better able to tolerate PAP treatment with a nasal mask. The tongue can also be involved in the obstruction of sleep apnea, by collapsing to the back of the throat during sleep. Some surgical procedures focus in diminishing the size of the tongue and by "tacking" it in place so it won't slip back to block the throat.
All the above surgeries are phase 1 surgeries. The main phase 2 surgery involves reconstruction of the bones of the upper and lower jaw, causing them to move forward and thereby enlarging the airway. While very successful, in terms of improvement of sleep apnea, it is a long and technically difficult procedure.
In our next blog I hope to complete our discussion of OSA and its variety of treatment options.
Published On: March 17, 2008