Surgery for sleep apnea
Obstructive sleep apnea can have serious physiological consequences. These effects are due to hypoxemia (lower blood oxygen levels) and sleep fragmentation caused by a steady collapse of the upper airway during sleep. This collapse causes complete or partial cessation of breathing during sleep termed apnea or hypopnea respectively.
Sleep apnea is a serious health problem
Obstructive sleep apnea is a relatively common condition. The apnea-hypopnea index (AHI) indicates the amount of apneas (10 second respiratory arrest) and hypopneas (decreased respiration) an individual experiences per hour and is used to determine sleep apnea severity. An AHI of less than 5 is normal. Sleep apnea is considered mild if the AHI is under 15, moderate if the AHI is between 15 and 30 and severe if the AHI is greater than 30. As sleep apnea severity increases, so does the risk for cognitive impairment (decreased concentration, memory problems, impaired jugement), psychological problems (irritability, depression), and systemic consequences (hypertension, pulmonary hypertension, cardiac arrhythmias, cardiac dysfunction, stroke, death)
In most cases, sleep apnea can be corrected by surgery. The procedures we practice include tracheotomy, orthognathic surgery, uvulopalatopharyngoplasty (UPPP), laser or radiofrequency-assisted uvulopalatoplasty (LAUP), tongue reduction by surgery or radiofrequency, nasal airway reconstruction, and tonsil and adenoids removal.
Tracheotomy was the first surgical procedure used to treat obstructive sleep apnea. In the 70’s and 80’s, it was frequently performed, but its use has since diminished in light of its numerous drawbacks. Complications related to permanent tracheotomy include tracheal stenosis, large blood vessel erosion, recurrent purulent bronchitis, vocal difficulties, and compromised aesthetics.
Orthognathic surgery, mandibular advancement
This surgery is indicated for obstructive sleep apnea that is secondary to a retrognathic mandible (i.e. posterior positioning of the lower jaw relative to the face and upper jaw). Surgically advancing the lower jaw opens the upper airway and at greater amplitudes this can effectively treat sleep apnea. Mandibular advancement can be performed alone or with genioglossal advancement (tongue muscle) or genioplasty (chin advancement).
UPPP was first introduced in 1964 to treat snoring. A more aggressive version was later developed to treat sleep apnea by not only modifying the soft palate, but by also removing redundant tissue from the lateral pharyngeal walls. Although UPPP significantly improves snoring in 90% of cases, its success rate for obstructive sleep apnea is only around 30-40%. This is in part due to the fact that structures such as the tongue base and nasal cavity remain untreated and may continue to obstruct the upper airway. Furthermore, post-operative fibrosis and scarring of the soft palate may also exacerbate sleep apnea longterm.
Complications related to UPPP include nasal regurgitation, velopharyngeal insufficiency (communication between nasal cavity and mouth), speech problems (hypernasality), palatine stenonis, and residual sleep apnea. Nowadays UPPP is rarely used as it has been replaced by procedures such as laser assisted uvulopalatoplasty (LAUP) and radiofrequency assisted uvulopalatoplasty.
Laser assisted uvulopalatoplasty (LAUP)
The LAUP has become increasingly popular to treat snoring with interesting initial success rates. This procedure is less invasive and recovery is easier than with UPPP. However, the effectiveness of this laser surgery to treat sleep apnea, shows disappointing results with less than 20% of patients with satisfactory response, 35% with only little or no response and almost 30% had an exacerbation of their symptoms after surgery.
Tongue reduction by radiofrequency
A large tongue or macroglossia may be present in patients with obstructive sleep apnea. If this is the case, a procedure to reduce the volume of the tongue can help reduce the symptoms and the disease. Traditional surgeries for tongue reduction are very painful. Fortunately, radiofrequency had recently yielded the same result with a less invasive approach. Indeed, this technique only takes a few minutes, is painless, and recovery is quick. Postoperative pain is relatively small and well controlled by analgesics. Patients can return to their regular activities the day after surgery.
Some interventions like nasoseptoplastie, turbinate removal or turbinectomie, nasal polypectomy or nose cartilage reconstruction may be necessary in patients with nasal obstruction that show a functional deformity at this level. Nasal reconstruction is an adjuvant treatment that cannot solve a sleep apnea problem by itself. When combined with other therapies, it will resume to a better condition.
Enlarged tonsils and adenoids may contribute to airway obstruction in the nasopharynx and oropharynx. This is especially observed in children and adolescents. A 3D tomography exam and a naso-pharyngoscopy will allow to assess the presence of hypertrophic tonsils or adenoids and determine whether or not an intervention at this level will be beneficial to solve a sleep apnea or snoring problem.
Maxillary advancement surgery (orthognathic surgery)
Orthognathic surgery is increasingly used to treat severe obstructive sleep apnea. Several studies have demonstrated excellent success rate, over 90% of reduction or elimination of severe sleep apnea in patients who underwent maxillary advancement by orthognathic surgery. This is the only effective surgical treatment in patients with severe apnea. Orthognathic surgery has also other benefits as it corrects facial deformities and patient malocclusions. This improves masticatory function, dental health and facial aesthetics.
Electrical stimulation of the upper airway
For patients who can not tolerate therapy through positive pressure ventilation, there is an airway stimulation therapy. This surgical technique involves placing an electrode under the skin at the neck level and more precisely near the hypoglossal nerve. The goal is to send stimulation to the respiratory tract via a small electrical box, located at the chest. The procedure is obviously performed under general anesthesia. The experimental phases have proven effective even though the therapy is currently practiced in only a few countries. At least 18 million Americans are affected by OSA. In North America, where clinical testing sites for the electronic airway pacemaker are developing, we consider this as a scourge, just like diabetes and asthma.