If you suffer from obstructive sleep apnea (OSA) and haven’t been able to tolerate positive airway pressure (such as CPAP, BiPAP, or APAP), you may want to consider sleep apnea surgery. Various types of surgery for sleep apnea are designed either to help you tolerate positive airway pressure more easily or to treat your obstructive sleep apnea by itself. Learn more about sleep apnea surgeries and which might be best for you.
Sleep Apnea Surgery For CPAP Therapy
Of the many reasons that you may have trouble sleeping comfortably wearing a CPAP, two are narrow nasal passages (often causing nasal obstruction or congestion) and high CPAP pressures.
Narrow Nasal Passages
CPAP equipment can be difficult to wear if you have narrow nasal passages because the therapy is often delivered through the nose. In these cases, opening the nasal passages, which can be done with medications or surgery, has been shown to improve the ability of patients to use CPAP.
The most common nasal surgical procedure involves septoplasty and turbinate reduction. This sleep apnea surgery consists of an outpatient procedure that straightens out the septum and reduces the size of the turbinates (long, narrow passageways). This allows for more room in the nose which lets air pass smoothly and without effort.
High CPAP Pressures
You may require high CPAP pressures to treat your sleep apnea problems. While this is meant to be a treatment for sleep apnea, issues may arise related to the high pressure. One of the most common side effects is difficulty exhaling against the pressure.
Blocked nasal passages and enlarged tonsils or adenoids are two possible reasons why you may be having a negative experience with CPAP pressures. If this is something you struggle with, consider these treatments for sleep apnea.
- Nasal passage surgery: As mentioned above, nasal passage procedures like septoplasty may help open up your airways and allow for improved breathing.
- Tonsillectomy: This surgery for sleep apnea is most often done in children, but can be used for adults as well. It involves the removal of the tonsils (two small glands) located in the back of the throat.
- Adenoidectomy: Like tonsillectomies, an adenoidectomy is usually performed at a young age. This sleep apnea surgery removes the adenoids in the roof of the mouth behind the soft palate where the nose connects to the throat.
All of these procedures relating to the nose, tonsils, and adenoids can potentially help you tolerate CPAP therapy. The goal of these surgeries is to make CPAP as comfortable as possible.
Surgery For Sleep Apnea
If you are unable to sleep comfortably using CPAP in spite of your best efforts, obstructive sleep apnea surgery may be an option. Before diving into details concerning surgery for sleep apnea, there are three important considerations you should know. One, not all surgeries are the same. Two, sleep apnea patients should only consider procedures that are well-suited to them. Three, not everyone is a good candidate for surgery.
Treatments for sleep apnea that directly target obstructive sleep apnea address blockage of breathing in the throat, either in the area behind the soft palate (roof of the mouth) or behind the tongue and epiglottis. Procedures can be broadly classified by the area of the throat (or, in some cases, the specific body structure) that they treat. These procedures can either be performed alone or, if you are thought to have blockage in more than one area of the throat, in combination.
Palate Procedures for Sleep Apnea
This category of sleep apnea surgeries includes uvulopalatopharyngoplasty (UPPP), expansion sphincter pharyngoplasty, lateral pharyngoplasty, uvulopalatal flap, the pillar procedure, palatal advancement pharyngoplasty, z-palatoplasty, and relocation pharyngoplasty.
In general, these procedures involve removing the tonsils (if they have not been removed previously) and removing or repositioning of the soft palate, uvula, and soft tissues next to the palate and tonsils on the side of the throat. While each surgery for sleep apnea has its own complex process, here is a quick summary of each.
- Uvulopalatopharyngoplasty (UPPP): This sleep apnea surgery includes the removal of the uvula and a portion of the soft palate, as well as sewing together the cut edges of the remaining portion of the soft palate and sides of the throat.
- Expansion sphincter pharyngoplasty: In this OSA surgery, the muscle that is directly behind the tonsil (palatopharyngeus muscle) is freed up from the side of the throat and moved forward. Because it is still attached to the soft palate, it pulls the soft palate forward to open the area behind the soft palate for breathing.
- Lateral pharyngoplasty: This surgery for sleep apnea involves extensive repositioning of tissue of the soft palate, as well as the lateral pharyngeal tissues (side of the throat).
- Uvulopalatal flap: In this procedure, the lining of the mouth (mucosa) found on a portion of the soft palate, as well as the uvula, are removed to allow a folding of the soft palate muscle onto itself.
- Pillar procedure: This OSA surgery typically involves the insertion of 3-5 braided polyester implants (pillars) into the soft palate at the back of the mouth.
- Palatal advancement pharyngoplasty: This surgery for sleep apnea treats the palate by removing some of the bone towards the back of the roof of the mouth (hard palate). After removal of the bone, the soft palate is then pulled forward and sewn into place.
- Z-palatoplasty: This sleep apnea surgery requires dividing part of the soft palate in the middle and pulling each half forward and laterally.
- Relocation pharyngoplasty: In this OSA surgery, the procedure involves sewing together the muscles on the side of the throat to open the space for breathing.
Hypopharyngeal procedures treat the area of the throat behind the tongue and epiglottis, which has been called the hypopharyngeal, retrolingual, or retroglossal region. This group of procedures includes tongue radiofrequency, genioglossus advancement, tongue stabilization, partial glossectomy, and hyoid suspension. These procedures either shrink, tighten, or reposition tissues that surround the lower portion of the throat. Here is a description of each.
- Tongue radiofrequency: This procedure involves a controlled cauterization of the tongue muscle.
- Genioglossus advancement: In this type of procedure, a surgeon cuts the portion of the lower jaw where the muscle attaches and pulls the small piece of bone forward to bring the anchor point of the tongue forward.
- Tongue stabilization: This sleep apnea surgery starts with a skin incision on the neck where a screw is placed on the inside of the central part of the lower jaw. A stitch is attached to this screw and passed through the tongue on one side and brought back through the other side. As the stitch is tied down, it reduces the ability of the tongue to move around.
- Partial glossectomy: This refers to a number of surgeries for sleep apnea that involve removal of a portion of the tongue.
- Hyoid suspension: Through a neck incision, this OSA surgery secures the hyoid bone either slightly downwards to the thyroid cartilage or upwards to the lower jaw.
Other Sleep Apnea Surgery Options
As if there weren’t enough treatments for sleep apnea already, there are more surgeries available to you if you are a prime candidate.
Inspire Upper Airway Stimulation
Inspire upper airway stimulation is a new and exciting OSA surgery that involves placing a medical device inside the body so that it can function somewhat like a pacemaker for the tongue during sleep. The system is controlled by a small remote device that you can turn on and off yourself. The surgery is done under general anesthesia, but most patients are able to go home as quick as the next day.
Jaw Advancement Surgery
This surgery for sleep apnea, also known as maxillomandibular advancement or bimaxillary advancement, is another surgical option. This procedure treats sleep apnea by moving the upper and lower jaws forward. It enlarges the space for breathing in the throat because the structures that surround the throat are effectively attached to the jaws. Advancing the jaws moves these structures forward, reducing their ability to produce blockage in the throat.
Maxillomandibular advancement surgery has demonstrated better results than the procedures listed above, but this procedure has more substantial risks and a longer recovery time.
Risks of Sleep Apnea Surgery
Just as there are potential risks for any other type of invasive surgery, there are risks for patients who undergo OSA surgery. These risks fall into two categories: risks of health complications and risks specific to individual procedures.
The risks of serious health complications have been studied best for soft palate surgery. Results have shown that the risk is estimated at 1.2% (1/80). A key factor to remember is that people are much more likely to have these complications if they had significant medical problems before surgery (which is also true for other surgeries).
Before choosing a sleep apnea surgery, it is crucial to consult with your doctor and go through a thorough medical examination in order to make sure you are healthy enough to handle surgery. If you struggle with one or more serious health issues, you may not be a good candidate for OSA surgery.
Because these procedures treat structures of the throat, there are potential procedure-specific complications including troubles with swallowing, speech, taste, and tongue numbness or weakness.
There is also controversy about results of sleep apnea surgery. As with other surgeries, there isn’t a guarantee that you will experience a permanent fix to your problem. With OSA surgery, different patients experience different results and it really depends on a variety of factors. However, certain surgeries have been found to be more successful than others.
Research and consult with your doctor about the best course of action for you and your case of sleep apnea.
Overall, there are countless sleep apnea surgeries available to people struggling with obstructive sleep apnea. If traditional methods like CPAP and BiPAP haven’t worked for you, it may be time to consider one of the surgeries listed above. As always, make an appointment with your doctor to discuss the options that may work for you.
NOTE: Inspire and Upper Airway Stimulation are trademarks of Inspire Medical Systems, who is not affiliated with this website.
Author: Eric Kezirian, MD, MPH