Sleep apnea surgical treatment


 * Associate Editor(s)-In-Chief: Kashish Goel, M.D.

Children
Most children with obstructive sleep apnea have the problem on the basis of chronically enlarged tonsils and adenoids. In these children, tonsillectomy and adenoidectomy is curative. The operation may be far from trivial, however, in the worst cases, in which growth is reduced and abnormalities of the right heart may have developed. Even in these extreme cases, however, the surgery tends to cure not only the apnea and upper airway obstruction - but to allow subsequent normal growth and development. Once the high end-expiratory pressures are relieved, the cardiovascular complications reverse themselves. The postoperative period in these children requires special precautions (see surgery and obstructive sleep apnea syndrome below). A number of different surgeries are available to improve the size or tone of a patient's airway. For decades, tracheostomy was the only effective treatment for sleep apnea. It is used today only in rare, intractable cases that have withstood other attempts at treatment. Modern operations employ one or more of several options, tailored to each patient's needs. Long term success rates are low, resulting in most doctors favoring CPAP.
 * Nasal surgery, including turbinectomy (removal or reduction of a nasal turbinate), or straightening of the nasal septum, in patients with nasal obstruction or congestion which reduces airway pressure and complicates OSA.
 * Tonsilectomy and/or adenoidectomy in an attempt to increase the size of the airway.
 * Removal or reduction of parts of the soft palate and some or all of the uvula, such as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP). Modern variants of this procedure sometimes use radiofrequency waves to heat and remove tissue.
 * Reduction of the tongue base, either with laser excision or radiofrequency ablation.
 * Genioglossus Advancement, in which a small portion of the lower jaw that attaches to the tongue is moved forward, to pull the tongue away from the back of the airway.
 * Hyoid Suspension, in which the hyoid bone in the neck, another attachment point for tongue muscles, is pulled forward in front of the larynx.
 * Maxillomandibular advancement (MMA). A more invasive surgery usually only tried in difficult cases where other surgeries have not relieved the patient's OSA, or where an abnormal facial structure is suspected as a root cause. In MMA, the patient's upper and lower jaw are detached from the skull, moved forward, and reattached with pins and/or plates.
 * Pillar procedure, three small inserts are injected into the soft palate to offer support, potentially reducing snoring in mild to moderate sleep apnea

Special situation: surgery and anesthesia in patients with sleep apnea syndrome
Many drugs and agents used during surgery to relieve pain and depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing.

Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided.

Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction-swelling may negate some of the effects in the immediate postoperative period.

Individuals with sleep apnea generally require more intensive monitoring after surgery for these reasons.