Adults with obstructive sleep apnea (OSA) who are unable to tolerate positive airway pressure (such as CPAP, BiPAP, or APAP) may want to consider sleep apnea surgery. Surgery can be designed either to help someone tolerate positive airway pressure more easily or to treat OSA by itself.

Surgery To Help You Use CPAP More Easily

Of the many reasons that you may have trouble sleeping comfortably wearing CPAP, two are narrow nasal passages (often causing nasal obstruction or congestion) and high CPAP pressures.  Because CPAP is often delivered through the nose, if you have narrow nasal passages, CPAP can be difficult to wear.  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 wear CPAP.  Some patients that require high CPAP pressures to treat their sleep apnea have problems related to these high pressures, such as difficulty breathing out against the high pressure.  Two possible causes of high CPAP pressures that can respond to surgery are blockage in the nasal passages or enlarged tonsils or adenoids.  In these cases, treatment of the nasal passages, tonsillectomy, or adenoidectomy can reduce CPAP pressures and improve your comfort with CPAP.

Surgery to Treat Your OSA

If you are unable to sleep comfortably with continuous positive airway in spite of best efforts, surgery to treat your OSA may be an option. There are three important things to know about surgery: that not all surgeries are the same, that patients should only consider procedures that are well-suited to them, and that not everyone is a good candidate for surgery.

The procedures that treat OSA 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 include 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 removal of the tonsils (if they have not been removed previously) and involve removal or repositioning of the soft palate, uvula, and soft tissues next to the palate and tonsils on the side of the throat. UPPP was first described for the treatment of OSA in 1982, and the development of other procedures has occurred because UPPP does not do enough to treat OSA for many patients. UPPP is still performed commonly, but other soft palate procedures have shown better results than UPPP in subgroups of patients, including randomized studies in some cases.

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.

Inspire Upper Airway Stimulation is an exciting new treatment that involves surgery to place a medical device inside the body so that it can function somewhat like a pacemaker for the tongue during sleep. See Hypoglossal nerve stimulation

Jaw advancement surgery (called 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 recovery.

For more information, see Hypopharyngeal Procedures and Jaw Advancement Surgery

Risks of Sleep Apnea SurgerySnoring Mouth Picture

Risks fall into two categories: risks of health complications and those specific to individual procedures. The risks of serious health complications have been studied best for soft palate surgery; the risk was estimated at 1.2% (1/80), but a key is that people were much more likely to have these complications if they had significant medical problems before surgery (also true for other surgeries).  Therefore, you are not as good a candidate for OSA surgery if you have significant medical problems. 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 controversy about results of sleep apnea surgery.  Another risk of surgery is that even after surgery patients may continue to experience sleep apnea (which also can occur after other treatments, including CPAP).

Inspire and Upper Airway Stimulation are trademarks of Inspire Medical Systems, who is not affiliated with this website.

Author: Eric Kezirian, MD, MPH

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