Sleep Apnea

Description

Surgery

Surgery is sometimes recommended, usually by throat specialists, for severe obstructive apnea. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.

Uvulopalatopharyngoplasty (UPPP)

The Procedure. Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.

The Goal of Surgery. The object of UPPP is threefold:

• To increase the width of the airway at the throat's opening.
• To block some of the muscle action in order to improve the ability of the airway to remain open.
• To "square off" the soft palate to improve its movement and closure.

Success Rates. Success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term. Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate, which may or may not involve the tonsils. Results are poor if the problems involve other areas or the full palate. In such cases CPAP is superior. In one study, sleeping on the side (rather than the back) after surgery boosted success rates significantly.

Complications. Uvulopalatopharyngoplasty is among the most painful treatments for sleep apnea, and recovery takes several weeks. It is recommended only for select patients with severe obstructive sleep apnea. The procedure also has a number of potentially serious complications. In fact, in one study, 42% of patients had complaints about the procedure. Some complications include the following:

• Infection. (In one study this complication was so common that 40% of patients needed another operation because of it.) Preventive antibiotics administered an hour before surgery can help reduce this risk.
• Impaired function in the soft palate and muscles of the throat.
• Mucus in the throat.
• Changes in voice frequency.
• Swallowing problems.
• Regurgitation of fluids through the nose or mouth.
• Impaired sense of smell.
• Failure and recurrence of apnea. In such cases, continuous positive airway pressure (CPAP) is often less effective afterward, although one study found that oral appliances may still help.

In one review of studies, 20% of patients who had UPPP required tracheostomy afterward. Most of these complications can be avoided with proper technique and experienced surgeons.

Laser-Assisted Uvulopalatoplasty (LAUP)

A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a physicians office. At this time, however, long-term success rates from LAUP are very modest, particularly for reducing apneas. Some physicians, in fact, are concerned that if LAUP eliminates snoring, then a diagnosis of apnea may be missed in patients who have the more serious condition.

Common complications include throat dryness (over 50%). Throat narrowing and scarring have been reported. In a minority of patients, snoring becomes worse afterward.

Tracheostomy

Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:

• The surgeon makes an opening through the neck into the windpipe and inserts a tube.
• It is almost 100% successful, but it requires a quarter-size opening in the throat. This produces a number of medical and psychological problems associated with recovery.

Today, this is performed rarely, usually only if sleep apnea is life-threatening. A procedure that uses only a tiny opening may prove to be a good alternative.

Radiofrequency Ablation

A technique called radiofrequency ablation is of interest:

• It uses radio waves emitted from an electrode to treat patients who snore.
• The radio waves heat, stiffen, and shrink a small amount of tissue at the base of the tongue.
• The therapy takes about twenty minutes and can be done in a doctors office.
• It typically requires 10 treatments within five or six sessions. (A newer form requires fewer treatment sessions because it provides more concentrated radio waves, and it appears to be effective.)
• It is far less invasive than standard surgery and results in far less pain and fewer complications. Discomfort can be controlled with simple pain relievers.

Studies are reporting significant improvement in reduced snoring and less daytime sleepiness for some patients, although as with other surgeries, the benefits may be short term in the majority of patients. It may be helpful for mild obstructive sleep apnea.

Other Procedures

Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. They may include the following:

• Tongue advancement, in which an opening is cut where the tongue joins the jawbone and the area is pulled forward.
• Genioplasty, which is plastic surgery on the chin.
• Hyoid surgery, in which the movable bone underneath the chin is moved forward, pulling the tongue muscle along with it.
• Maxillary or maxillomandibular advancement (MMA), which moves the upper (maxilla) and/or lower (mandible) jawbone forward. (A survey of patients who had MMA found that the surgery changed their facial appearance, but most people thought it was a change for the better.)
• Surgery for nasal obstructions (such as a deviated septum) that contribute to snoring and other symptoms.
• Snoreplasty injection is a recent nonsurgical procedure to correct snoring due to soft palate fluttering. The procedure involves injecting materials called sclerosants that can stiffen the soft palate. In one study, it reduced snoring in 92% of patients, but snoring returned in 18% of them. At this time, it has no role for people with sleep apnea.

Removing Adenoids and Tonsils in Children

Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for children and adolescents with sleep apnea. It cures the condition in 75% to 100% of cases, including in many children who are obese. Complications include respiratory illness, which occurs in about one-fourth of children after the surgery. Children at highest risk for respiratory complications are with the following conditions:

• Being under three years old.
• Severe sleep apnea.
• Heart complications.
• Failure to thrive.
• Obesity.
• Prematurity.
• Recent lung infections.
• Certain facial structures.
• Neuromuscular disease.

The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.

Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.

Investigative Approaches

Hypoglossal Nerve Stimulation. In a small study, a small implantable electrical device that stimulates the hypoglossal nerve, which is under the tongue, during inspiration eased symptoms of obstructive sleep apnea. Further testing of this experimental technique is needed.

Speeding up Pacemakers. One intriguing 2002 study of people with sleep apnea and who had pacemakers found that when the pacemakers were increased to 15 beats per minute faster than the average nighttime rate patients reported improvement in sleep apnea. Some experts theorize that sleep apnea in patients with slow heart rates may be due to common problems in the nerves that affect the muscles in the heart and the throat. It is possible that drugs that increase heart rate may prove a novel method for treating the disorder, though further study is needed.