Although I'm a sleep surgeon, I consider myself an integrative sleep apnea physician first. Sleep apnea is more than just treating a blockage like plumbing. You have to look at the whole person: physical, emotional, psychological and even spiritual. If you start by looking at the family history, down to the patient's birth conditions, geographic location, and ethnic background, you'll see all the factors that contribute to what we describe the end result called obstructive sleep apnea. This is why you have to address the person's dietary, exercise, nutritional, and stress-related needs first. You have to make the patient understand clearly why treating sleep apnea is so important. Having the doctor tell you that you have to treat it won't work. The motivation has to start from within.
There so many myths and misconceptions about sleep apnea surgery, and in most cases, you're asking the wrong question. In one sense, sleep apnea surgery works 100%, but not everyone will choose to undergo a tracheotomy. But what people call sleep apnea surgery usually doesn't work because of the misconception that there's always one area, like the soft palate, that causes obstruction. For a more detailed explanation of the myths and truths about sleep apnea surgery, you can find out more information on my website - I have a detailed, long report. I also go into much more detail why all modern humans have sleep breathing problems in my book.
Over the years, both CPAP proponents and surgery proponents have perpetuated many myths and even falsehoods that continue even in this forum. The bottom line is that whether it's CPAP, surgery, or oral appliances, they all work well to various degrees, but only if applied properly and in the appropriate patients. CPAP is still the gold standard, but if you look at the number of people using CPAP after 3-5 years after starting, I'll bet much less than 20 to 30% are using it on a regular basis. It only works if you're using it. The main problem in most cases is that preparation, follow-up and support by sleep professionals are lacking in most cases. The same problem exists with oral appliances, with various levels of experience within the dental community. It's not so much which device is the best, but which is the best dentist, regardless of the device. The same goes for surgeons. Two different surgeons performing the same operation can have two different results.
The other major problem with sleep apnea surgery is that not too many surgeons understand that obstruction occurs in the entire upper airway, from the tip of the nose to the voice box. If you have nasal congestion, large tonsils and tongue collapse, taking out the tonsils or performing a UPPP won't help. If you address all the appropriate areas of obstruction and do the procedures properly, then your success rates can be up to 80% for soft tissue operations and 95% for major skeletal procedures. If you're in the unfortunate 5% that underwent a skeletal operation, it didn't work for you, but it did work in 95% of others, so it's not fair to say that you should never do it, just because you didn't respond.
The other major myth is that UPPP surgery can prevent CPAP use. It's probably happened to someone somewhere in the world, but as far as I know, there are no studies documenting this. In fact, most studies show that even if an operation doesn't work, CPAP pressures can be lowered, making CPAP tolerance much easier, especially if you undergo nasal surgery to relieve nasal congestion. Somehow, this myth about palatal surgery started to be applied all kinds of surgery, including nasal and tongue base surgery.
If you talk to the pioneers of sleep medicine, they'll all agree that UARS and OSA begins with jaw narrowing. Everyone has muscle relaxation when in deep sleep, but the smaller your airway due to smaller jaws, the more likely you'll obstruct. Obesity and weigh gain come in much later, which only aggravates the problem.
There are various ways of using CPAP and oral appliances, and some people have to experiment with different options.
You'll see various studies on the usefulness of imaging studies or the value of sleep endoscopy to see where the obstruction is happening. What I found many years ago is that what you see in these studies doesn't add anything new compared to doing a good physical exam, especially with the patient lying flat. For some reason, Most ENTs, dentists, and sleep doctors never look at the upper airway in the supine position. There are some elegant studies using pressure sensors showing that the most common area of obstruction after UPPP failure is the tongue base.
Ultimately, my job as a surgeon is to do everything possible to avoid surgery. This is why the vast majority of patients that come to me for surgical opinions are able to go back to using CPAP or oral appliances more effectively, after extensive counseling and management of these various other factors. But if they've exhausted everything and have no other choice, I'll offer surgery, making sure that all the different levels are addressed. There are some patients that still don't respond to surgery, but most patients' lives are changed dramatically of the better, and this is what motivates me to continue to offer surgery, but only as a last resort.
Sorry for rambling.
Steven Y. Park, M.D.