Surgical Treatment of Obstructive Sleep Apnea (OSA)

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Surgical Treatment of Obstructive Sleep Apnea (OSA)

Surgical Procedures
Adult Sleep Medicine
Author Credentials 

Maria Suurna, MD
Assistant Professor
Department of Otolaryngology, Head and Neck Surgery
Weill Cornell Medicine
New York, NY

Module Summary

Despite of the effectiveness of PAP in OSA treatment, significant percentage of patients are unable to adhere to this treatment long-term. Surgery is a treatment option for patients with OSA who unable to tolerate or have failed less invasive treatment options. Proper patient selection is essential to surgical success. Individual anatomic and non-anatomic factors should be taken into consideration when deciding on surgical procedures.

Module Learning Objectives 
  1. Recognize the indications for surgery for OSA.
  2. Describe methods of preoperative airway evaluation.
  3. List available surgical procedures for obstructive sleep apnea, their risks and relative success rates.

Anatomy

Learning Objectives 
  1. Understand the head and neck anatomy and the relation to OSA.
    • Tonsil size classification
    • Fujita classification
    • Freidman staging
  2. Describe nasal anatomy and its role in OSA.
  3. Describe craniofacial anatomy and correlation between the anatomic structures to the severity of OSA.
  4. Describe hypoglossal nerve anatomy and innervation of the tongue muscles.
References 
  1. Kerr P, Millar T, Buckle P, Kryger M. The importance of nasal resistance in obstructive sleep apnea syndrome. J Otolaryngol. 1992;21:189-95.
  2. Rama AN, Tekwani SH, Kushida CA. Sites of obstruction in obstructive sleep apnea. Chest. 2002;122:1139-47.
  3. Neelapu et al. Craniofacial and upper airway morphology in adult obstructive sleep apnea patients: A systematic review and meta-analysis of cephalometric studies. Sleep Med Rev. 2017 Feb;31:79-90.
  4. Rowley JA, Aboussouan LS, Badr MS. The use of clinical prediction formulas in the evaluation of obstructive sleep apnea. Sleep. 2000 Nov 1. 23(7):929-38. 
  5. Friedman M, Tanyeri H, La Rosa M, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope. 1999;109:1901-7.
  6. Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg. 2002;127:13-21.
  7. Friedman M, Ibrahim H, Joseph NJ. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope. 2004;114:454-9.
  8. Mu L, Sanders I. Human Tongue Neuroanatomy: Nerve Supply and Motor Endplates. Clinical Anatomy. 23:777–791 (2010).
  9. Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clin North Am. 1989;36:1551–1569.

Pathogenesis

Learning Objectives 

See Anatomy and pathogenesis in Obstructive Sleep Apnea Module. 

Patient Evaluation

Learning Objectives 
  1. Understand physical exam and findings for surgical evaluation
  2. Discuss the role of Muller maneuver and awake endoscopy
  3. Describe Drug Induced Sleep Endoscopy (DISE) and its role in surgical planning
    • DISE technique
    • Reliability data for DISE interpretation
    • VOTE classification
      • Common findings on VOTE classification
References 
  1. Katsantonis GP, Corey SM, Walsh JK. The predictive efficacy of the Muller maneuver in uvulopalatopharyngoplasty. Laryngoscope.1989;99:677-80.
  2. Terris DJ, Hanasono MM, Liu YC. Reliability of the Muller maneuver and its association with sleep-disordered breathing. Laryngoscope. 2000;110(11):1819–1823.
  3. Hohenhorst W. et al., Drug-induced sleep endoscopy in adults with sleep-disordered breathing: Technique and the VOTE Classification system. Operative Techniques in Otolaryngology. 2012 Mar;23(1):11-18. 
  4. De Vito A, Carrasco Llatas M, Vanni A, et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath. 2014;18:453–465.
  5. Certal VF et al. Awake Examination Versus DISE for Surgical Decision Making in Patients With OSA: A Systematic Review. Laryngoscope. 2016 Mar;126(3):768-74.
  6. Vanderveken OM, Maurer JT, Hohenhorst W, et al. Evaluation of drug induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep apnea. J Clin Sleep Med. 2013;9:433–438.
  7. Vroegop AV, Vanderveken OM, Boudewyns AN, et al. Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases. Laryngoscope. 2014;124:797–802.
  8. Rodriguez-Bruno K, Goldberg AN, McCulloch CE, Kezirian EJ. Test-retest reliability of drug-induced sleep endoscopy. Otolaryngol Head Neck Surg. 2009 May;140(5):646-51.
  9. Kezirian EJ, White DP, Malhotra A, Ma W, McCulloch CE, Goldberg AN. Interrater reliability of drug-induced sleep endoscopy. Arch Otolaryngol Head Neck Surg. 2010 Apr;136(4):393-7.
  10. Ravesloot MJ, de Vries N. One hundred consecutive patients undergoing drug-induced sleep endoscopy: results and evaluation. Laryngoscope. 2011 Dec;121(12):2710-6.

Imaging

Learning Objectives 
  1. Describe the following imaging studies, their diagnostic significance, and useful measures.
    • Cephalometric roentgenograms.
    • Computed tomography/magnetic resonance imaging

 

References 
  1. Schwab RJ. Upper airway imaging. Clin Chest Med. 1998;19:33-54.
  2. Neelapu BC et al. Craniofacial and upper airway morphology in adult obstructive sleep apnea patients: A systematic review and meta-analysis of cephalometric studies. Sleep Med Rev. 2017 Feb;31:79-90.
  3. Abramson Z, Susarla S, August M, Troulis M, Kaban L. Three-dimensional computed tomographic analysis of airwayanatomy in patients with obstructive sleep apnea. J Oral Maxillofac Surg. 2010 68(2):354–362.
  4. Susarla SM, Abramson ZR, Dodson TB, Kaban LB. Cephalometric measurement of upper airway length correlates with the presence and severity of obstructive sleep apnea. J Oral Maxillofac Surg. 2010 68(11):2846–2855.
  5. Barrera JE. Sleep magnetic resonance imaging: dynamic characteristics of the airway during sleep in obstructive sleep apnea syndrome. Laryngoscope. 2011 121(6):1327–1335.
  6. Bhattacharyya N, Blake SP, Fried MP. Assessment of the airway in obstructive sleep apnea syndrome with 3-dimensional airway computed tomography. Otolaryngol Head Neck Surg. 2000;123:444–9.
  7. Suratt PM, Dee P, Atkinson RL, et al. Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis. 1983;127:487–92.

Surgical Therapies

Learning Objectives 
  1. Understand the indications for surgical treatment.
  2. Define surgical success and surgical cure.
  3. Discuss anesthetic management in patients with OSA.
  4. Understand the role of surgery in improving CPAP compliance.
  5. Describe office based procedures for treatment of OSA, indications and success rate
    • Inferior turbinate reduction
    • Laser assisted uvulopalatoplasty
    • Radiofrequency ablation of the base of tongue
    • Palatal stiffening procedures
    • Pillar implant
  6. Describe surgical procedures for treatment of OSA, indications and success rate
    • Nasal surgery
      • Septoplasty
      • Turbinate reduction
      • Polypectomy
      • Endoscopic sinus surgery
      • Nasal valve reconstruction
      • Functional rhinoplasty
    • Nasopharynx
      • Adenoidectomy
    • Palatal surgery
      • Uvulopalatopharyngoplasty (UPPP)
      • Advancement pharyngoplasty
      • Expansion palatopharyngoplasty
    • Oropharynx
      • Tonsillectomy
      • Expansion pharyngoplasty
      • Uvulopalatopharyngoplasty.
      • Expansion palatopharyngoplasty
    • Hypopharynx
      • Hyoid suspension
    • Genioglossus advancement
    • Tongue surgery
      • Radiofrequency tongue base reduction
      • Tongue stabilization
      • Partial glossectomy
        • Lingual tonsillectomy
        • Endoscopic midline glossectomy
        • SMILE
        • Transoral robotic surgery (TORS)
    • Epiglottis
      • Epiglottopexy
      • Epiglottectomy
    • Maxillomandibular advancement
    • Hypoglossal nerve stimulation implant
    • Tracheostomy
  7. Discuss indications for single vs multilevel surgery.
References 
  1. Randerath WJ et al. Non-CPAP therapies in obstructive sleep apnoea.  European Respiratory Society task force on non-CPAP therapies in sleep apnoea. Eur Respir J. 2011 May;37(5):1000-28.
  2. Ishii et al.  Does Nasal Surgery Improve OSA in Patients with Nasal Obstruction and OSA? A Meta-analysis. Otolaryngol Head Neck Surgery. 2015 Sep;153(3):326-33. 
  3. Camacho M, Riaz M, Capasso R, et al. The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis. Sleep. 2015;38:279–286.
  4. Friedman M et al. Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2003 Dec;129(6):611-21.
  5. Woodson et al.  Expansion sphincter pharyngoplasty and palatal advancement pharyngoplasty: airway evaluation and surgical techniques. Operative Techniques in Otolaryngology. 2012 Mar;23(1);3-10. 
  6. Farrar J, Ryan J, Oliver E, Gillespie MB. Radiofrequency ablation for the treatment of obstructive sleep apnea: a meta-analysis. Laryngoscope. 2008 Oct;118(10):1878-83.
  7. Justin GA, Chang ET, Camacho M, Brietzke SE. Transoral Robotic Surgery for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. Otolaryngol Head Neck Surg. 2016 May;154(5):835-46.
  8. Barrera JE. Skeletal Surgery for Obstructive Sleep Apnea. Otolaryngol Clin North Am. 2016 Dec;49(6):1433-1447.
  9. Vicini C et al.  Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an emerging surgical technology in a targeted application for benign disease. ORL J Otorhinolaryngol Relat Spec. 2014;76(2):63-9.
  10. Miller SC, Nguyen SA, Ong AA, Gillespie MB. Transoral robotic base of tongue reduction for obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2017 Jan;127(1):258-265.
  11. Heiser C et al. Updates of Operative Techniques for Upper Airway Stimulation. Laryngoscope. 2016 Sep;126 Suppl 7:S12-6.
  12. Strollo PJ, Soose RJ, Maurer JT, et al., STAR Trial Group. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014;370:139–149.
  13. Motta J, Guilleminault C, Schroeder JS, et al. Tracheostomy and hemodynamic changes in sleep-inducing apnea. Ann Intern Med.1978;89:454-58.
  14. Choi JH, Cho SH, Kim SN, Suh JD, Cho JH. Predicting Outcomes after Uvulopalatopharyngoplasty for Adult Obstructive Sleep Apnea: A Meta-analysis. Otolaryngol Head Neck Surg. 2016 Dec;155(6):904-913.
  15. Pang et al. Expansion sphincter pharyngoplasty: A new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007 Jul;137(1):110-4.
  16. Pang KP, Pang EB, Win MT, Pang KA, Woodson BT. Expansion sphincter pharyngoplasty for the treatment of OSA: a systemic review and meta-analysis. Eur Arch Otorhinolaryngol. 2016 Sep;273(9):2329-33.
  17. Woodson BT, Toohill RJ. Transpalatal advancement pharyngoplasty for obstructive sleep apnea. Laryngoscope.1993 Mar;103(3):269-76.
  18. Woodson BT1, Robinson S, Lim HJ. Transpalatal advancement pharyngoplasty outcomes compared with uvulopalatopharygoplasty. Otolaryngol Head Neck Surg. 2005 Aug;133(2):211-7.
  19. Volner K, Dunn B, Chang ET, Song SA, Liu SY, Brietzke SE, O'Connor P, Camacho M. Transpalatal advancement pharyngoplasty for obstructive sleep apnea: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2017 Mar;274(3):1197-1203.
  20. Ho WK, Wei WI, Chung KF. Managing disturbing snoring with palatal implants: a pilot study. Arch Otolaryngol Head Neck Surg. 2004 Jun;130(6):753-8.
  21. Friedman M, Vidyasagar R, Bliznikas D, Joseph NJ. Patient selection and efficacy of pillar implant technique for treatment of snoring and OSA/hypopnea syndrome. Otolaryngol Head Neck Surg. 2006;134:187-196.
  22. Gillespie MB, Wylie PE, Lee-Chiong T, Rapoport DM. Effect of palatal implants on continuous positive airway pressure and compliance. Otolaryngol Head Neck Surg. 2011 Feb;144(2):230-6.
  23. Choi JH, Kim SN, Cho JH. Efficacy of the Pillar implant in the treatment of snoring and mild-to-moderate obstructive sleep apnea: a meta-analysis. Laryngoscope. 2013 Jan;123(1):269-76.
  24. Rotenberg BW, Luu K. Four-year outcomes of palatal implants for primary snoring treatment: a prospective longitudinal study. Laryngoscope. 2012 Mar;122(3):696-9.
  25. Baba RY, Mohan A, Metta VV, Mador MJ. Temperature controlled radiofrequency ablation at different sites for treatment of obstructive sleep apnea syndrome: a systematic review and meta-analysis. Sleep Breath. 2015 Sep;19(3):891-910.
  26. Sher E, Kenneth B, Jay F. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;19:156-77.

Complications

Learning Objectives 

Describe complications of surgical procedures

Resources 

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