Sleep Procedures

Surgical management of snoring and OSA is indicated when a surgically correctable abnormality is believed to be the source of the problem and the patient has tried continuous positive airway pressure (CPAP) without success. In addition, many patients opt for surgical treatment after noninvasive forms of treatment have proven ineffective or difficult to tolerate.

Surgical alteration of the upper airway usually involves 1 or more structures in the nose, mouth and throat. When surgical therapy is indicated, conservative procedures are attempted first. These procedures include uvulectomy, nasal reconstruction, adenotonsillectomy, and palatal implants. More aggressive operations include uvulopalatopharyngoplasty (UPPP, or UP3) and genioglossal advancement with hyoid myotomy. Second-line treatments for OSA are more complex and include maxillary-mandibular advancement, bimaxillary advancement, palatal advancement and tongue- base surgery (midline glossectomy), and tracheostomy.

A patient with a large uvula who snores and has few or no symptoms of apnea may benefit from uvulectomy. The patient can be given local anesthesia, and uvulectomy can be performed as an office procedure by using cautery or a carbon dioxide laser. The procedure consists of incising the inferior rim of the soft palate and uvula. The tonsils are not removed.

Pillar system
The Pillar procedure, involving the insertion of palatal implants, is a minimally invasive operation used to treat people with habitual snoring and those with mild to moderate OSA. The Pillar procedure addresses the soft palate, which is one of the anatomic components of sleep apnea and snoring. During the Pillar procedure, 3 tiny, woven inserts are placed in the soft palate to help reduce the vibration that causes snoring and the ability of the soft palate to obstruct the airway. Once in place, the inserts add structural support to the soft palate. Over time, the body's natural tissue response to the inserts increases the structural integrity of the soft palate. This procedure can be performed in the office or in the operating room as an adjunctive procedure.

Nasal reconstruction
Relief of nasal obstruction alone rarely cures OSA; however, patient tolerance and response to nasal CPAP are often improved. Septoplasty, septorhinoplasty, and turbinate reduction may be indicated in patients who have a predisposed anatomy. Turbinates can be reduced in a number of different ways, including through traditional total or partial turbinectomies, submucous resection, cryotherapy, laser vaporization, bipolar radiofrequency coblation, and radiofrequency ablation. Regardless, the reduction in the size of the turbinate helps to alleviate nasal congestion.

Nasal reconstruction
Adenotonsillectomy Adenotonsillectomy is often performed in the pediatric population to correct loud snoring and restless sleep. OSA is the primary indication for tonsillectomy in the pediatric population. The tonsils and adenoids can be removed or reduced in a number of ways. The surgeon’s preference, the cost of the procedures, and postoperative pain and complications dictate which methods are used by each surgeon. The choice of which procedures are employed is subject to change over time.

Palatal surgery
UPPP is the most common procedure for the treatment of OSA syndrome. This procedure, introduced by Fujita in 1981, is like a face-lift for the throat and involves removal of the tonsils and a portion of the soft palate. Transpalatal advancement pharyngoplasty has also been described and includes the removal of a portion of the posterior hard palate and anterior suspension of the soft palate. This procedure has evolved because of the unpredictable success of UPPP, but it is not widely performed in the United States.

Genioglossal advancement
Genioglossal advancement involves performing a mandibular osteotomy with forward movement of the genioglossus-attached segment of the mandible. This procedure results in forward displacement of the tongue.

Thyrohyoid suspension
This procedure involves making a horizontal incision in the midline of the neck and advancing the hyoid bone anteriorly and inferiorly to the thyroid cartilage.

Maxillary-mandibular advancement
Maxillary-mandibular advancement is performed in an attempt to widen the airway while maintaining the existing dental occlusion or, optimally, improving it. A wide variety of maxillomandibular advancement techniques have been described, all with the goal of advancing skeletal support for the tongue and pharynx.

Permanent tracheotomy cures OSA and is indicated most often in patients with severe apnea that is associated with life-threatening cardiac arrhythmias. Other less frequent indications may include morbid obesity, obstruction with severe hypoxia, and disabling daytime somnolence. This is not commonly used today.