Surgical Treatment of Obstructive Sleep Apnea: Upper Airway and Maxillomandibular Surgery

Abstract

Upper airway surgery is an important treatment option for patients with obstructive sleep apnea (OSA), particularly for those who have failed or cannot tolerate positive airway pressure therapy. Surgery aims to reduce anatomical upper airway obstruction in the nose, oropharynx, and hypopharynx. Procedures addressing nasal obstruction include septoplasty, turbinectomy, and radiofrequency ablation (RF) of the turbinates. Surgical procedures to reduce soft palate redundancy include uvulopalatopharyngoplasty, uvulopalatal flap, laser-assisted uvulopalatoplasty, and RF of the soft palate with adenotonsillectomy. More significant, however, particularly in cases of severe OSA, is hypopharyngeal or retrolingual obstruction related to an enlarged tongue, or more commonly due to maxillomandibular deficiency. Surgeries in these cases are aimed at reducing the bulk of the tongue base or providing more space for the tongue in the oropharynx so as to limit posterior collapse during sleep. These procedures include genioglossal advancement, hyoid suspension, distraction osteogenesis, tongue RF, lingualplasty, and maxillomandibular advancement. Successful surgery depends on proper patient selection, proper procedure selection, and experience of the surgeon. Most surgeries are done in combination and in a multistep manner, with maxillomandibular advancement typically being reserved for refractory or severe OSA, or for those with obvious and significant maxillomandibular deficiency. Although not without risks and not as predictable as positive airway pressure therapy, surgery remains an important therapeutic consideration in all patients with OSA. Current research aims to optimize the success of these procedures by identifying proper candidates for surgery, as well as to develop new invasive procedures for OSA treatment.

Positive airway pressure and electrical stimulation methods for obstructive sleep apnea treatment: a patent review (2005 – 2014)

“…Surgical (nasal, oropharyngeal and hypopharyngeal procedures, maxillomandibular advancement, and hyoid suspension), medical (CPAP, custom-made oral appliances), behavioral (weight loss, positional therapy), and pharmacological (supplemental oxygen, modafinil) approaches are currently the main alternatives for OSAHS treatment [3,6,20,35,36]. Table 1 summarizes the main alternatives currently available for OSAHS treatment, their advantages and limitations.…”

Non-positive airway pressure therapy for obstructive sleep apnea

“…UPPP involves tonsillectomy, trimming, and reorientation of the posterior and anterior tonsillar pillars, and excision of the uvula and soft palate [150]. As a result, soft palate redundancy can be reduced and upper airway obstruction improves [150].…”

“…As a result, soft palate redundancy can be reduced and upper airway obstruction improves [150]. This technique was the dominant treatment of OSA before CPAP was generally available [151].…”

“…However, additional nonpalatal sites of upper airway obstruction are present in most of the obese OSA patients [153]. As a result, in most of the studies, the effectiveness of UPPP varies, showing only 50 % success rate (definition of success was 50% reduction in AHI after surgery) in non obese, mild to moderate sleep apnea patients [150,153,154]. Moreover, not only the efficacy of UPPP seems to diminish over time [155], but UPPP is also significantly less effective than the MADs [155].…”

Orthodontics and sleep-disordered breathing

“…The combination of the best soft tissue surgery and the bi-bloc mandibular advancement device might lead to better outcomes than soft-tissue surgery and geniotubercle advancement. The bi-bloc mandibular advancement device alone may provide similar efficacy compared to the geniotubercle advancement but with less risk and complications [6,7]. OSA management clearly requires both otolaryngologists and orthodontists.…”