Sleep Apnea Surgery

Sleep apnea is a condition in which a person repeatedly stops or nearly stops breathing while they sleep. Treatment for sleep apnea depends on the type of condition diagnosed, the sleeper’s medical history, and the severity of their symptoms.

The most common form of sleep apnea, called obstructive sleep apnea (OSA), occurs when a person’s airway collapses during sleep. Treatment for OSA often begins with lifestyle changes and positive airway pressure (PAP) therapy. When these treatments aren’t enough, a doctor may recommend alternative treatments such as oral appliances or surgery.

Central sleep apnea (CSA) is a less common form of sleep apnea that happens when the brain doesn’t properly signal the body to breathe. Treatment for CSA targets the underlying medical cause of the condition. Treatment may also include therapies that assist breathing using PAP therapy, supplemental oxygen, medication, or surgery.

If you’ve been diagnosed with sleep apnea, you may want to know if surgery is an option for you. We cover several types of surgery used to treat sleep apnea and how each procedure helps to reduce nighttime breathing disruptions.

Mouth and Throat Surgery

The most common surgeries for OSA focus on addressing physical features in the mouth and throat that contribute to a narrowed or collapsed airway.

Uvulopalatopharyngoplasty (UPPP)

The most common surgery for OSA is uvulopalatopharyngoplasty. The purpose of UPPP is to keep the airway from collapsing during sleep by addressing obstructions within the upper portion of the throat, including the uvula (a small tissue flap at the back of the throat), tonsils, and a group of muscles in the roof of the mouth called the soft palate.

Most people see an improvement in snoring after UPPP and about 50% experience a significant reduction in breathing issues during sleep, though a complete cure for OSA is uncommon with this procedure.

Pharyngoplasty

Pharyngoplasty describes several variants of UPPP that target specific areas of the throat that may be contributing to OSA.

  • Lateral pharyngoplasty: A lateral pharyngoplasty is a surgery that involves removing the tonsils before cutting a muscle within the walls of the throat and attaching it to a muscle that runs from the tongue to the soft palate.
  • Expansion sphincter pharyngoplasty: This surgery involves removal of the tonsils and part of the uvula and repositioning of several muscles in the throat.
  • Transpalatal advancement pharyngoplasty: Another variation of UPPP, transpalatal advancement involves removing a portion of the hard palate to shift it forward and prevent the soft palate from collapsing and blocking the airway.

Adenoid or Tonsil Removal

Surgery to address obstructions in the upper portion of the throat often includes the removal of the adenoids, tonsils, or both. The adenoids are glands located behind the nose, while the tonsils are lower in the back of the throat. Enlarged adenoids or tonsils are associated with a greater risk for OSA, especially in children.

For children over 2 years old diagnosed with OSA, the recommended first-line treatment is the removal of both the adenoids and tonsils during a procedure called an adenotonsillectomy. Adenotonsillectomy is among the most common surgical procedures for children in the United States.

Tracheostomy

For people with severe OSA who don’t respond to less invasive treatments, doctors may recommend a tracheostomy. During a tracheostomy, a permanent opening is made in the neck to create an alternate airway and facilitate breathing.

Although a tracheostomy is nearly always effective in resolving OSA, this procedure changes a person’s appearance and may affect their quality of life. For these reasons, it is only recommended when other treatments aren’t successful at resolving severe symptoms.

Jaw Surgery

Doctors may recommend a jaw surgery to treat OSA called maxillomandibular advancement (MMA). During this procedure, both the upper and lower jaws are shifted forward to enlarge the portion of the throat at the back of the mouth.

This surgery may be recommended for people with a jaw that is set further back and isn’t recommended for older adults or people with large necks.

Tongue Surgery

During sleep, the tongue may block the airway and contribute to obstructive sleep apnea. Several procedures can reduce airway blockages caused by the tongue.

Tongue Reduction

Tongue reduction is a surgery that decreases the size of the tongue. There are several types of tongue reduction surgery. One type is called a midline glossectomy, where tissue from the middle of the tongue is removed. Another is a lingualplasty, where tissue on the sides of the tongue is removed.

Tongue reductions are often performed in addition to UPPP and other surgeries to the mouth and throat. About 60% of people who have tongue reduction surgery experience improvements in nighttime breathing and daytime symptoms of OSA.

Genioglossus Advancement

The genioglossus muscle makes up the majority of the tongue’s mass and helps it move from side to side. This muscle also helps keep the airway open, so if it becomes too relaxed during sleep it may constrict or block the airway. Genioglossus advancement is a surgery that brings this muscle forward in the mouth to keep it from obstructing the airway during sleep.

Genioglossus advancement is often performed in addition to other surgeries such as UPPP. While the success rates for this procedure vary widely between studies, one large study found that over half of people who have the procedure experience significant improvements in their nighttime breathing.

Hyoid Suspension

The hyoid bone is a U-shaped bone near the top of the throat that is attached to the underside of the tongue and nearby muscles. The hyoid plays a role in the movements and functions of the mouth and face, including keeping the airway open and supporting tongue movement. The position of the hyoid can make a person more prone to airway collapse and OSA.

Hyoid suspension is a surgery that brings the hyoid bone forward and stabilizes its position. Research shows that hyoid suspension can successfully treat OSA when performed alongside other surgeries.

Nasal Surgery

Nasal surgeries may be recommended for people with OSA who have obstructions that originate in the nose. Issues that may affect breathing include a deviated septum, where the wall dividing the two halves of the nose are off-center, growths in the sinuses or lining of the nose, and swelling of tissue around structures within the nose called turbinates.

While nasal surgeries may improve sleep quality, there is limited evidence that nasal surgeries effectively treat OSA on their own. Instead, nasal surgeries can improve the effectiveness of other treatments such as continuous positive airway pressure (CPAP) or oral appliances.

There are many types of nasal surgeries that may be recommended for people with OSA.

  • Septoplasty: In a septoplasty, a deviated septum is repaired to improve the nasal airway.
  • Turbinate reduction: Swollen turbinates can occur as a result of a deviated septum. Reducing this tissue can help keep the airway open.
  • Endoscopic sinus surgery: If nasal polyps inhibit breathing, they can be removed in a procedure called endoscopic sinus surgery.
  • Rhinoplasty: A rhinoplasty can repair issues in the nose that cause breathing disruptions, including abnormalities caused by injury.
  • Nasal valve surgery: The nasal valves are the narrowest portion of the nose, which limits airflow when a person breathes through their nose. Nasal valve surgery attempts to resolve obstructions originating in this area.

Nerve Stimulation Surgeries

Nerve stimulation attempts to reduce breathing disruptions using devices that are surgically implanted in the body. There are two different nerve stimulation surgeries used to treat sleep apnea. Hypoglossal nerve stimulation (HNS) is a treatment for obstructive sleep apnea. Transvenous phrenic nerve stimulation (PNS) is a treatment for central sleep apnea.

Hypoglossal Nerve Stimulation (HNS)

During this procedure, a medical device is surgically implanted into the area of the chest below the collarbone. The device sends electrical currents to the hypoglossal nerve, which directs the tongue and nearby muscles. When the hypoglossal nerve is stimulated, the tongue shifts forward in the mouth and prevents it from blocking the airway.

Around 80% of people who have HNS see a decrease in the severity of their OSA, a reduction in overall sleepiness, and an improved quality of life.

Transvenous Phrenic Nerve Stimulation (PNS)

Phrenic nerve stimulation is a treatment for central sleep apnea. PNS involves implanting a medical device in the chest to stimulate the phrenic nerve which causes the diaphragm to contract. CSA is caused by a lack of signals from the brain that control breathing, so stimulating the phrenic nerve can help a person breathe more normally.

Although preliminary research shows that PNS may reduce the number of nighttime awakenings and improve daytime symptoms, there is limited research on its long-term effects and how it compares to other treatments for CSA.

Surgery Compared to Other Sleep Apnea Treatments

While there are a number of surgeries for obstructive sleep apnea, health care providers typically recommend less invasive therapies to treat sleep apnea prior to considering surgery. Common treatments for adults with sleep apnea include lifestyle changes, CPAP, BiPAP, and oral appliances.

  • Lifestyle changes: Limiting the use of alcohol before bedtime, exercising regularly, and quitting smoking are all recommended strategies for improving OSA. If your OSA gets worse when you sleep on your back, your doctor might recommend transitioning to sleeping on your side.
  • CPAP: CPAP is widely regarded as the most effective treatment for adults with OSA. CPAP is also a first-line treatment for the most common type of central sleep apnea. A CPAP machine delivers constant air pressure to keep the airway open during sleep.
  • BiPAP: Similar to CPAP, bilevel positive airway pressure (BiPAP or BPAP) delivers pressurized air to support the airway. However, BiPAP provides air at a higher pressure during inhalation and lower pressure during exhalation.
  • Oral appliances: An oral appliance is designed to shift the jaw forward and keep the airway open during sleep. Oral appliances are the most common form of OSA treatment after CPAP.

Talk to Your Doctor About Surgery for Sleep Apnea

Before considering surgery to treat sleep apnea, your doctor will likely recommend lifestyle changes, CPAP or other therapies. If these approaches do not sufficiently treat your symptoms or they are too difficult to maintain, your doctor may suggest surgery either alone or in combination with other sleep apnea treatments.

If your doctor recommends surgery for sleep apnea, it may be helpful to ask about the risks and benefits associated with the procedure, recovery times, and expected outcomes, as these can vary among sleep apnea surgeries.

References

+26 Sources

  1. Accessed on September 3, 2022. https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-obstructive-sleep-apnea-in-adults
  2. Accessed on September 3, 2022. https://www.uptodate.com/contents/management-of-obstructive-sleep-apnea-in-adults
  3. Accessed on September 3, 2022. https://www.merckmanuals.com/home/lung-and-airway-disorders/sleep-apnea/sleep-apnea
  4. Accessed on September 3, 2022. https://www.uptodate.com/contents/central-sleep-apnea-treatment
  5. Accessed on September 3, 2022. https://www.uptodate.com/contents/surgical-treatment-of-obstructive-sleep-apnea-in-adults
  6. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/14603056/
  7. Accessed on September 3, 2022. https://www.ncbi.nlm.nih.gov/books/NBK551654/
  8. Accessed on September 3, 2022. https://www.ncbi.nlm.nih.gov/books/NBK549823/
  9. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/31892966/
  10. Accessed on September 3, 2022. https://medlineplus.gov/ency/article/003013.htm
  11. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/29371899/
  12. Accessed on September 3, 2022. https://www.uptodate.com/contents/management-of-obstructive-sleep-apnea-in-children
  13. Accessed on September 3, 2022. https://www.uptodate.com/contents/adenotonsillectomy-for-obstructive-sleep-apnea-in-children
  14. Accessed on September 3, 2022. https://www.uptodate.com/contents/tracheostomy-rationale-indications-and-contraindications
  15. Accessed on September 3, 2022. https://emedicine.medscape.com/article/295807-treatment
  16. Accessed on September 3, 2022. https://www.ncbi.nlm.nih.gov/books/NBK545141/
  17. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/30709536/
  18. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/27742106/
  19. Accessed on September 3, 2022. https://www.ncbi.nlm.nih.gov/books/NBK539726/
  20. Accessed on August 29, 2022. https://pubmed.ncbi.nlm.nih.gov/34356971/
  21. Accessed on September 3, 2022. https://medlineplus.gov/ency/article/002983.htm
  22. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/18197014/
  23. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/28901030/
  24. Accessed on September 3, 2022. https://www.ncbi.nlm.nih.gov/books/NBK532869/
  25. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/31699408/
  26. Accessed on September 3, 2022. https://pubmed.ncbi.nlm.nih.gov/32946372/