Wrong! Surgery can be highly effective for both snoring and OSAS. People—physicians or lay people—who say otherwise are simply showing their ignorance as to the developments in this arena over the past decade or more. That’s one reason this website was created.
This section of the website includes discussion on the following topics. You may scroll through the entire section or may click on the topic that interests you the most.
Introduction
to snoring and OSAS surgery
The theory behind OSAS surgery
Snoring | Laser treatment of snoring
|
Somnoplasty | Uvulopalatopharyngoplasty | CPAP |
Sleep Study
Obstructive Sleep Apnea | Sinus, allergy
and nasal disorders
Tod C. Huntley, MD |
Stephen B. Freeman, MD | Richard W.
Borrowdale, MD
Head & Neck Surgery
Introduction
to snoring and OSAS surgery
Obstructive sleep apnea is to a great extent a mechanical problem of the upper airway. It occurs when the throat is narrowed or blocked off by something that is too long, too thick, too floppy, or relaxes too much during sleep. Luckily, a variety of surgical procedures are available that can shorten, tighten, rearrange, bypass, or reduce the bulk of these tissues. It can therefore be argued that virtually any patient with OSA should be offered the opportunity to undergo surgical correction of his or her sleep apnea problem.
What follows are descriptions of the various surgical techniques which are the most effective, and which can singly or in conjunction cure nine out of ten patients, no matter how severe the OSAS. Some of these procedures are widely taught in surgical training programs and are therefore universally available; others are more complicated techniques that are only offered in a limited number of specialized centers. All of them are available through Dr. Huntley and his associates.
In the past, the only surgery offered to obstructive sleep apneic patients was a tracheotomy, which bypasses the obstruction, no matter where it might arise. Patient acceptance of this therapy was poor, however. Attention later turned to partial excision of the soft palate and uvula (uvulopalatopharyngoplasty, or UPPP). For the last two decades such palatal surgery in its various incarnations has been the primary surgery offered to snoring and OSAS patients.
Yet this palatal surgery cures only about 41% of patients with sleep apnea. This is because OSAS is generally due to obstruction in more than one level of the upper airway. The obstruction is frequently due to a combination of the palate and the tongue base, and to a lesser extent, the nose. This introduces the concept of “disproportionate anatomy.” This term describes the fact that many patients with OSAS have a combination of several different factors, which in combination conspire to block off the airway during sleep. These problems can include any or all of the following: a long and thick palate; enlarged tonsils; excessive and redundant tissue at the back of the throat; small lower jaw; enlarged tongue; and/or a low-lying hyoid bone.
Successful surgical treatment of OSAS therefore requires that each area of collapse be addressed in a systematic way. A variety of effective surgical approaches have been devised in recent years to deal with each of these areas.
When such a region-specific surgical approach utilized, cure rates of 90% or more can be offered to patients, though it may require more than one surgical procedure.
To better understand the concept of region-specific surgery for OSAS, sleep apnea surgeons think of the throat as though it consists of two distinct regions--the retropalatal (behind the palate) and the retrolingual (behind the tongue) regions. One often-used classification scheme, the Fujita classification, categorizes these two areas as follows:
q Type I: Retropalatal obstruction alone. This includes most non-apneic snorers and mild sleep apneics. Such patients should respond well to palatal surgery as the primary form of treatment.
q Type II: Both retropalatal and retrolingual obstruction. Most patients with significant OSAS are generally thought to fit into this category. Successful surgical outcome in these patients requires that both the palate and the tongue base be addressed.
q Type III: Retrolingual obstruction alone. This is thought to be the least common anatomic configuration.
The various surgical procedures that will be discussed below include the most common ones that address the various areas of potential obstruction. Regardless which surgical procedures are performed, postoperative sleep study confirmation of success is necessary when significant OSAS is being treated. Likewise, it is recommended that whenever possible, patients with significant OSAS have their airways stabilized perioperatively with nasal CPAP. Such patients are healthier for surgery, as they have no sleep debt, have better pulmonary function, have less upper airway swelling, and can tolerate larger doses of pain medicines.
Information on snoring and sleep apnea
| Snoring | Laser treatment of snoring
|
Somnoplasty | Uvulopalatopharyngoplasty | Tongue
base surgery | CPAP |
Sleep Study
Obstructive Sleep Apnea | Sinus, allergy
and nasal disorders
Tod C. Huntley, MD |
Stephen B. Freeman, MD | Richard W.
Borrowdale, MD
Head & Neck Surgery
Before discussing the region-specific surgical approaches that are performed for OSAS, the tracheotomy will be briefly presented. A tracheotomy, or trach for short, is a small hole that is placed in the trachea, or windpipe, below the vocal cords. The hole is generally stented open by a small trach tube that is kept unplugged at night, so that the person breathes through the hole. The tube can be capped off during the day, so that the person can breathe and talk normally. Since the tissues that block off the airway in sleep apnea are located above the trach site, the surgery is by definition 100% successful, as it bypasses all potential levels of upper airway obstruction.
Though not as frequently performed now that other treatment modalities are available, patient acceptance of this surgical approach is better now that less-conspicuous self-retaining trach tubes (referred to as stoma stents) have in recent years become available.
Dr. Huntley generally offers a tracheostomy to the
following types of patients: those who are too ill to undergo more definitive
upper airway reconstruction; some CPAP-intolerant severe sleep apneics who need
a safer, more secure airway before undergoing upper airway surgery; and those
who want a guaranteed “quick fix.” If
subsequent upper airway reconstructive surgery corrects the sleep apnea, the
tracheostomy can be removed. The
hole then closes on its own, or can be closed by a brief outpatient procedure.
Proper nasal airflow is important in maintaining quiet and restful sleep. Much of the total upper airway resistance during sleep—up to 40% to 50%--comes from the nasal cavities. Even partial nasal obstruction can contribute significantly to sleep apnea by increasing upper airway resistance. In addition, nasal obstruction can result in an open mouth-breathing pattern, which causes the lower jaw, or mandible, to rotate down and back. This results in narrowing of the airway behind the tongue, which may already be narrowed by the patient’s underlying anatomy. It is therefore important to keep the nose as healthy as possible.
Correction of nasal obstruction may therefore reduce or eliminate snoring, improve sleep apnea, and may allow for better CPAP compliance. Nasal surgery alone is rarely enough to cure significant sleep apnea, however. The patients most likely to be cured by nasal surgery are those with snoring or apnea, normal pharyngeal anatomy, or recent onset of OSAS.
Some degree of prediction of the effectiveness of nasal surgery can be obtained by having the patient try an “Afrin Test.” This involves the use of a nasal decongestant spray (any brand is OK) just prior to bedtime on several nights to see if snoring and daytime sleepiness are affected. If so, it would suggest that nasal surgery should likewise be helpful. Patients must not use the spray as a treatment, however, as it is easy to get hooked on such sprays. When that happens, there is a paradoxical worsening of the nasal blockage over what was experienced beforehand. This rebound obstruction can occur after just five to seven days of continuous usage.
Among the most common causes of nasal obstruction are deviation or crookedness of the wall separating the two nasal cavities, referred to as the septum. It can be easily straightened by a simple outpatient surgical procedure, called a septoplasty. Other normal structures in the nose, the inferior turbinates, can also interfere with breathing in some people, and these can be easily reduced in size surgically. This surgery can at times be done painlessly under local anesthesia in the physician’s office. Other surgical procedures can remove nasal polyps and correct other forms of nasal blockage. These procedures can be performed on an outpatient basis, generally without the need for nasal packing, bruising, or significant discomfort.
The tongue base is the vertical portion of the tongue deep in the throat. The rationale for surgical treatment of the tongue base is that the majority of OSA involves obstruction at this level. It would therefore stand to reason that surgical techniques designed to relieve tongue base obstruction should have a large role in the treatment of OSA. Such techniques are not widely taught, however, and are therefore not offered by most surgeons. When part of a comprehensive surgical treatment plan, however, cure rates of 90% or more can be achieved. Click here for more information on tongue base surgery
Snoring | Laser treatment of snoring
|
Somnoplasty | Uvulopalatopharyngoplasty | CPAP |
Sleep Study
Obstructive Sleep Apnea | Sinus, allergy
and nasal disorders
Tod C. Huntley, MD |
Stephen B. Freeman, MD | Richard W.
Borrowdale, MD
Head & Neck Surgery