Elsevier

Sleep Medicine Reviews

Volume 18, Issue 5, October 2014, Pages 405-413
Sleep Medicine Reviews

Clinical review
Role of surgery in adult obstructive sleep apnoea

https://doi.org/10.1016/j.smrv.2014.02.003Get rights and content

Summary

A surgical approach to treatment of obstructive sleep apnoea (OSA) remains an area of intense debate, both within and without the surgical community itself. Continuous positive airway pressure (CPAP) therapy remains the gold standard for the treatment of OSA, however surgery may be indicated to facilitate CPAP and/or improve compliance in cases where CPAP is poorly tolerated.

This article summarises the current range of surgical treatment options together with the evidence base for their intervention in otolaryngology, maxillofacial and bariatric surgery. The continued evolution of technology has brought new surgical techniques to the fore and it seems likely their utilisation together with a multi-level surgical approach to the airway will continue to influence forthcoming research in OSA. Patient selection and precise evaluation will remain crucial in ensuring that when surgery is indicated, the correct procedure or procedures are performed at the correct anatomical level.

Introduction

Sleep related breathing disorder (SRBD) is used to describe a broad clinical spectrum of recurring partial or complete occlusion of the upper airway. This ranges from snoring to severe obstructive sleep apnoea (OSA). Population based studies demonstrate OSA syndrome affecting approximately 4% of males and 2% females, a level of prevalence comparable to Type I Diabetes [1]. The morbidity and mortality related to OSA is well recognised as an independent risk factor for hypertension, cardiovascular, and cerebrovascular diseases [2]. In addition neurobehavioral morbidities of daytime sleepiness and impaired cognitive function may contribute to motor vehicle and job-related accidents [3], [4]. Overall, OSA significantly increases the risk of stroke or death from any cause and in a community based sample moderate-to-severe sleep apnoea is independently associated with a large increased risk of all-cause mortality [5]. The obesity epidemic means problems faced by health professionals in relation to OSA is only likely to increase in the immediate future.

The selection of surgical treatments in OSA remains an area of intense debate, both within and without the surgical community itself. Fundamentally continuous positive airway pressure (CPAP) therapy remains the gold standard for the treatment of OSA, however surgery may be indicated to improve compliance and outcome in cases where CPAP is poorly tolerated. Other non-surgical measures that warrant consideration with demonstrated efficacy include use of oral appliances [6] and sleep position training [7]. Increasing recognition of the multi-level nature of anatomical obstruction means consequentially there exists a large variety of differing surgical techniques used by different surgical specialties in an attempt to combat this problem. In many countries the financial implications of surgical private practice has perhaps contributed to a degree of cynicism as to the range of available surgical procedures for OSA [8] (Table 1).

In this article we summarise the current range of surgical treatments together with the evidence base for their intervention. As such we explore measures enlisted not only by otolaryngologists but maxillofacial and bariatric surgical colleagues. The key aspect of surgery in OSA is selecting the right operation to tackle the individual's specific problem at the correct time. There is a clear distinction that needs to be made with respect to surgery indicated for simple snoring and surgery indicated for OSA.

Section snippets

OSA research: difficulties for the clinician

It is well recognised that there is a paucity of high quality randomised controlled trials for surgical interventions in OSA but it may additionally be highlighted that this is problem faced by surgery in general [9]. A recent systematic review indicates the heterogenous end-points used failing to provide any consistency of effect from laser-assisted uvulopalatoplasty or radiofrequency ablation on daytime sleepiness, apnoea reduction, quality of life or snoring [10]. Additionally defining

Intrinsic appeal of surgery for OSA

In the UK, clear Scottish intercollegiate guidelines network (SIGN) guidelines have been provided with a clear focus on primary non-surgical management for OSA given the interpreted poor current evidence base for intervention [16]. However success through CPAP, oral appliances or sleep position training is dependent on patient compliance [6], ∗[17]. It is important for clinicians to recognise the difficulties patients face with an appliance-based approach to OSA. Unfortunately, adherence rates

Assessment of OSA: a surgical perspective

Clinical assessment begins with observations of any obvious morphological features such as retrognathia or dental mal-occlusion, neck collar size and body mass index (BMI). Evaluation of the upper airway will assist in identifying any obstructive anatomical abnormalities contributing to turbulent airflow and is a vital precursor to any successful surgical procedure [20].

Anterior rhinoscopy using a simple nasal speculum allows visualisation of the anterior aspect of the nasal cavity and helps in

Investigation of OSA

In order to comprehensively establish if the patient is suffering from OSA or not, it is vital to arrange either a full hospital based polysomnography or an ambulatory home sleep study [24]. In order to localise the potential site of obstruction compromising the upper airway, numerous techniques have been described but none are entirely satisfactory. These include CT and MRI imaging, acoustic analysis, pressure transducer measurements and sleep nasendoscopy [25].

Sleep nasendoscopy (SNE)

Surgical management of OSA

An appropriate surgical philosophy would dictate that patients should not come to any harm and careful patient selection would ensure a better surgical outcome. An unrelenting enthusiasm for surgical intervention in OSA patients may certainly be criticised and instead the decision should be made with a team-based approach to assessment. It should be acknowledged that for certain individuals (e.g., those with a high BMI and multiple medical co-morbidities) surgery would not be in the patient's

Nasal surgery

Patients may present to the rhinologist for surgical intervention not for curative purposes but for adjunctive treatment to improve the efficacy of nasal continuous positive airway pressure (CPAP) [29]. Surgical procedures performed for SRBD includes septoplasty, septorhinoplasty, functional endoscopic sinus surgery, turbinate reduction and nasal valve surgery.

Quality of life assessment in OSA patients with nasal obstruction has been assessed. Surgically correcting an obstructed nasal airway

Tonsillectomy and radical palatal surgery

Tonsillectomy is a potential first line surgical treatment of OSA where oropharyngeal anatomy is compromised. In several case series, patients with mild, moderate and severe OSA with grade III or IV tonsils demonstrate a reduction in post-operative AHI by over 50% through tonsillectomy alone [34], [35].

Palatal surgery remains prominent in the otolaryngologists' surgical armamentarium for OSA. The more radical procedure of palatal resection is usually required when the minimally invasive

Laser assisted palatoplasty

The laser was first introduced in the 1980's as a high energy tool with improved surgical precision and was used in laser assisted uvulopalatoplasty (LAUP) under local anaesthesia. Kamami described a technique using CO2 laser delivered via a specially designed hand-piece with a back stop to prevent inadvertent laser injury to the posterior pharyngeal wall [42].

Kamami's original description recommended this office-based procedure performed under local anaesthesia to be repeated at about six

Minimally invasive palatal surgery and tongue base surgery

Minimally invasive palatal surgery under local anaesthesia may be conducted through injecting chemicals into the soft palate resulting in scarring and stiffening. This technique of “injection snoreplasty” utilises chemicals such as sodium tetradecyl sulphate to stiffen the soft palate [50]. This technique is not recommended in patients with OSA and even in simple snorers the results are not entirely satisfactory although some short-term benefits have been reported. Complications of palatal

Hypopharyngeal surgery for OSA

The involvement of the tongue base and epiglottis in snoring and OSA is usually under estimated and in many cases where palatal surgery has failed to achieve a successful outcome it may be due to the fact that identifying the contribution of the tongue or the epiglottis to the upper airway obstruction has been missed.

SNE is particularly useful in identifying exactly the nature of hypopharyngeal collapse in that in some cases it is just the case of a large tongue retracting posteriorly and

Transoral robotic surgery for OSA

A recent development in the surgical management of OSA is the use of da Vinci robot allowing transoral robotic surgery (TORS). This is being utilised for patients with severe OSA who have failed CPAP treatment and persistent hypopharyngeal obstruction following experiences in tongue base malignancy [60].

A minimally invasive telerobotic system allows excellent 3D visualisation, immaculate precision and absence of tremor. This improved access allows oropharangeal enlargement anteriorly through

Multi-level surgery of the upper airway

The benefits and efficacy of multi-level surgery of the upper airway in OSA is shown through mostly level IV evidence yet a recent meta-analysis is suggestive of patient benefit [54]. This included 1978 patients with multi-level sleep apnoea surgery involving at least two involved anatomic sites: nose, oropharynx and hypopharynx, gave a success rate of 66.4%. In this case a reduction of AHI less than 20 and a greater than 50% reduction was used to define success.

It is this area that perhaps

References (79)

  • J.E.C. Holty et al.

    Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis

    Sleep Med Rev

    (2010)
  • K.L. Haines et al.

    Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea

    Surgery

    (2007)
  • W. Lee et al.

    Epidemiology of obstructive sleep apnea: a population-based perspective

    Expert Rev Respir Med

    (2008)
  • N.S. Marshall et al.

    Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study

    Sleep

    (2008)
  • T. Young et al.

    Epidemiology of obstructive sleep apnea: a population health perspective

    Am J Respir Crit Care Med

    (2002)
  • H.K. Yaggi et al.

    Obstructive sleep apnoea as a risk factor for stroke and death

    N Engl J Med

    (2005)
  • K.A. Ferguson et al.

    Oral appliances for snoring and obstructive sleep apnea: a review

    Sleep

    (2006)
  • I. Permut et al.

    Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea

    J Clin Sleep Med

    (2010)
  • A.G. Elshaug et al.

    Upper airway surgery should not be the first line treatment for obstructive sleep apnoea in adults

    BMJ

    (2008)
  • K.A. Franklin et al.

    Effects and side-effects of surgery for snoring and obstructive sleep apnea – a systematic review

    Sleep

    (2009)
  • A.G. Elshaug et al.

    Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence

    Sleep

    (2007)
  • M.J.L. Ravesloot et al.

    Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnoea revisited

    Sleep

    (2011)
  • S. Sundaram et al.

    Surgery for obstructive sleep apnoea in adults

    Cochrane Database Syst Rev

    (2005)
  • C.J. Field et al.

    Clinical equipoise in sleep surgery: investigating clinical trial targets

    Otolaryngol Head Neck Surg

    (2011)
  • Scottish Intercollegiate Guidelines Network

    Management of obstructive sleep apnoea/hypopnoea syndrome in adults: a national clinical guideline

    (2003)
  • N. Powell

    Upper airway surgery does have a major role in the treatment of obstructive sleep apnea: “the tail of the dog.”

    J Clin Sleep Med

    (2005)
  • T.E. Weaver et al.

    Adherence to continuous positive airway pressure therapy: the challenge to effective treatment

    Proc Am Thorac Soc

    (2008)
  • B. Kotecha

    The nose, snoring and obstructive sleep apnoea

    Rhinology

    (2011)
  • S.R. Mallampati et al.

    A clinical sign to predict difficult tracheal intubation: a prospective study

    Can Anaesth Soc J

    (1985)
  • M. Friedman et al.

    Diagnostic value of the Friedman tongue position and Mallampati classification for obstructive sleep apnea: a meta-analysis

    Otolaryngol Head Neck Surg

    (2013)
  • B. Overland et al.

    Pulse oximetry: sufficient to diagnose severe obstructive sleep apnoea

    Sleep Med

    (2002)
  • C. Georgalas et al.

    Assessment of obstruction level and selection of patients for obstructive sleep apnoea surgery: an evidence-based approach

    J Laryngol Otol

    (2010)
  • C. Croft et al.

    Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea

    Clin Otolaryngol

    (1991)
  • B.T. Kotecha et al.

    Sleep nasendoscopy: a 10-year retrospective audit study

    Eur Arch Otorhinolaryngol

    (2007)
  • E. Chisholm et al.

    Oropharyngeal surgery for obstructive sleep apnoea in CPAP failures

    Eur Arch Otorhinolaryngol

    (2007)
  • H.Y. Li et al.

    Nasal surgery for snoring in patients with obstructive sleep apnoea

    Laryngoscope

    (2008)
  • T. Verse et al.

    Effect of nasal surgery on sleep-related breathing disorders

    Laryngoscope

    (2002)
  • M. Morinaga et al.

    Pharyngeal morphology: a determinant of successful nasal surgery for sleep apnoea

    Laryngoscope

    (2009)
  • V. Hoffstein et al.

    Treatment of obstructive sleep apnea with nasal continuous positive airway pressure

    Am Rev Respir Dis

    (1992)
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