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CONSIDERING SURGERY FOR OSA?

With obstructive sleep apnea (OSA), blockages somewhere in the airway occur repeatedly and cause breathing to stop for at least ten seconds and maybe for a minute or longer. The intention of surgery is to open the airway sufficiently to eliminate or to reduce obstructions to a clinically insignificant level. In order to do so, surgical therapy in adults often must reconstruct the soft tissues (such as the uvula and the palate) or the bony tissues (the jaw) of the throat.

If you have been diagnosed with OSA and are considering surgery, talk to a sleep specialist and/or experienced surgeon about the different procedures, the chances they will be effective for you with your anatomy and why, and the risks involved with surgery. Untreated sleep apnea can be harmful to your health, and surgery cannot always address all the points of obstruction. Eliminating the snoring does not necessarily eliminate the apneas. Sometimes surgery does not cure sleep apnea but reduces the number of apneas so that more treatment options are available to you and/or more comfortable. Yet in some circumstances, surgery may actually worsen the apnea.

Insurance typically covers surgery for sleep apnea but not all surgical procedures. However, insurance companies that initially refuse to pay for a surgery may be convinced otherwise upon an appeal that demonstrates the efficacy and appropriateness of the surgery in your case. Throat pain from the major surgeries varies but is generally significant, often for one to two weeks. Most surgical procedures for sleep apnea are conducted in a hospital under general anesthetic. (People with sleep apnea must be cautious about general anesthesia--no matter for what medical condition the surgery is--because of the effects anesthesia has on the airway. For more on this, see our statement Sleep Apnea and Same-Day Surgery.)

The most common surgery for sleep apnea is the uvulopalatopharyngoplasty, or UPPP procedure, which is intended to enlarge the airway by removing or shortening the uvula and removing the tonsils and adenoids, if present, as well as part of the soft palate or roof of the mouth. (The uvula is the tissue that hangs from the middle of the back of the roof of the mouth; the word comes from the Latin "uva" meaning "grapes.") According to the "Practice Parameters for the Treatment of Obstructive Sleep Apnea: Surgical Modifications of the Upper Airway," issued in 1996 by the American Academy of Sleep Medicine (formerly the American Sleep Disorders Association), the overall efficacy is 40.7%. A more recent surgery using a laser (laser-assisted uvulopalatoplasty or LAUP, a modification of the UPPP where the surgeon cuts the uvula with a laser) is performed for snoring. There is not yet enough information to say whether LAUP is effective for OSA.

A tracheotomy--the surgical creation of a hole in the trachea or windpipe below the site of obstructions--is the most effective surgery for OSA. Unacceptable to most people, it is generally reserved for serious apnea that has failed other treatment. The hole is plugged (and usually covered) during the day for normal breathing and unplugged during sleep so obstructions are bypassed. The site must be cleaned carefully daily to prevent infections.

Other surgical procedures include laser midline glossectomy and lingualplasty where part of the tongue is removed. Two others which try to enlarge the airway by moving the jaw forward are maxillomandibular osteotomy or advancement (MMO or MMA) and the two-part inferior sagittal mandibular osteotomy and genioglossal advancement with hyoid myotomy and suspension (GAHM). These surgeries have very high success rates but are long and involved surgeries (lasting several hours) with a significant recovery period and potential complications that patients may reject. As a rule, success rates for these complicated surgeries are higher when performed by an experienced surgeon. You may have to undergo more than one surgery to eliminate the apneas sufficiently.

Another but relatively new surgical procedure for sleep apnea, one typically done in the doctor's office, is radio frequency tissue ablation (RFTA), with the trade name Somnoplasty. Approved by the Food and Drug Administration in November of 1998, it is to shrink the size of the tongue and/or palate. Multiple treatments are often necessary, and it may be performed in conjunction with other therapies as well. RFTA is still viewed as a new procedure, and relatively little published data on the procedure are currently available. A different surgical system designed to treat OSA was approved by the FDA in February 1998. Known as the tongue suspension procedure (with the trade name Repose), it is intended to keep the tongue from falling back over the airway during sleep with a small screw inserted into the lower jaw bone and stitches below the tongue. Usually performed in conjunction with other procedures, this surgery is potentially reversible. No studies on the long-term success are available, and little clinical data to demonstrate the efficacy of the procedure have yet been published in a peer-reviewed journal.

In general, when weighing surgery, consider whether data on the safety and efficacy of the procedure have met the key standard of being published in a peer-reviewed medical journal and whether the cases studied are similar to yours. Surgery helps many, but effectiveness varies from person to person. (With any surgery, follow-up sleep studies are often adviseable.) If unsure about proceeding, you can get a second opinion. Only a doctor who has examined you and your airway can advise you on having surgery.

There are additional treatment options for OSA that do not require surgery, including devices to keep the airway open. As mentioned, some surgeries are performed to make using them more comfortable. Which treatment is right for you depends upon the severity of your OSA and other aspects of your medical condition. Talk to your doctor about what is best for you, and remember your doctor may take a step-wise approach to treatment.

Physicians who perform surgery for sleep apnea are most commonly otolaryngologists (specializing in the ears, nose, and throat) and oral and maxillofacial surgeons. If you are seeking a referral to a surgeon or a second opinion, you may find one through your physician or through a sleep center, and keep in mind that your insurance policy may require you to get a referral for a specialist and/or to see a specific provider.

As a non-profit organization, the American Sleep Apnea Association does not endorse or recommend any healthcare provider, company, or product. 8-00

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Medical Edge

Radio waves a surgical try to halt apnea


Dear Mayo Clinic: As a patient with obstructive sleep apnea, I’ve been told that there are three possible treatments: machine-assist, surgery or a dental appliance. A local doctor has recently started promoting a fourth possibility – a radiofrequency procedure. Would you be kind enough to give me your opinion of this treatment? – Seattle

Answer: Radiofrequency ablation, or RFA, is not a fourth category but merely one type of surgery – the other common alternatives being a traditional scalpel-based procedure and a laser technique – for dealing with obstructive sleep apnea.

Apnea occurs when muscle tissues in the back of the throat – those that support the soft palate, uvula, tonsils and tongue – relax during sleep and narrow or close your airway, which impairs breathing and lowers the level of oxygen in the blood. The brain then senses the situation and briefly rouses you from sleep; when you’re awake, those muscles retighten, causing the airway to reopen. This pattern can recur throughout the night, limiting your ability to reach deep phases of sleep and resulting in sleepiness during the day.

The common goal of the surgeries is to remove obstructive tissue so that your air passages will remain unblocked during sleep. RFA uses radiofrequency to heat such tissue, which subsequently scars. Less tissue is then present to block the airway. Though several treatment sessions may be necessary, RFA presents certain advantages over the scalpel- and laser-based surgical alternatives. It is a relatively simple outpatient procedure performed in a doctor’s office; it causes less pain than the other surgeries; and no serious adverse consequences have been reported.

While each surgery is said to “cure� sleep apnea, that is only partly true. They may not access all of the pertinent tissue, and each procedure’s effectiveness varies. While studies report improvements with regard to snoring, impact on obstructive sleep apnea remains unclear. A standard saying of physicians in the field is that for the scalpel-based procedure, “50 percent of patients will get about 50 percent better.� For the laser and radiofrequency procedures, percentages are worse.

The treatment of choice for most patients with obstructive sleep apnea is continuous positive airway pressure, whereby a machine delivers pressurized air through a mask placed over your nose. This pressure keeps the upper-airway passages open and prevents apnea. CPAP can be cumbersome for some people, however, and it has to be used every night.

For adults with milder cases and who have healthy jaws and teeth, an alternative is a dental device, placed over the teeth, that is designed to move the jaw forward. This action brings the tongue and some muscle tissue forward as well, which opens the throat. But dental devices can be considered intrusive, too.

A true fourth option for milder cases – as well as an adjunct for moderate and serious cases – is weight loss. Excess weight, especially around the throat, can cause or exacerbate obstructive sleep apnea. A rule of thumb is that each 10 percent weight reduction will reduce the frequency of apneas by 25 percent. Similarly, other risk-modifying actions – avoiding alcohol or sedatives, keeping the nose decongested and sleeping on the side or stomach instead of the back – may reduce the problem.

The lack of properly conducted clinical studies makes it difficult to define the role for surgery in obstructive sleep apnea. It may be the answer for people with obvious obstructing lesions of the throat and for individuals with milder cases. A partial cure (which surgery offers) can mean significant improvement for a person with a mild case. Any decision about surgery, however, should be made in close collaboration with a sleep specialist and an ear, nose and throat surgeon.

– Eric J. Olson, M.D., Sleep Disorders Center, Mayo Clinic, Rochester, Minn.

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Medical Edge from Mayo Clinic is a Tribune Media Services medical column that appears on Mind & Body Sundays. Write to Medical Edge, The Journal Gazette, P.O. Box 88, Fort Wayne, IN 46801-0088; fax, 461-8648; or e-mail jgnews@jg.net. For health information, visit www.mayoclinic.com.