Clinical reviewRole of surgery in adult obstructive sleep apnoea
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)
- et al.
Sleep apnoea patients have more automobile accidents
Lancet
(1987) - et al.
Polysomnography indexes are discordant with quality of life, symptoms, and reaction times in sleep apnea patients
Otolaryngol Head Neck Surg
(2005) - et al.
Surgical procedures for the treatment of obstructive sleep apnea
Semin Orthod
(2009) - et al.
Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery
Otolaryngol Head Neck Surg
(2004) - et al.
Clinical staging for sleep-disordered breathing
Otolaryngol Head Neck Surg
(2002) - et al.
Modification of Z-palatoplasty technique and review of five-year experience
Oper Techn Otolaryngol
(2012) - et al.
Trans palatal advancement pharyngoplasty outcomes compared with uvulopalatopharygoplasty
Otolaryngol Head Neck Surg
(2005) - et al.
Injection snoreplasty: how to treat snoring without all the pain and expense
Otolaryngol Head Neck Surg
(2001) - et al.
Lingual tonsil reduction in OSA: transcervical radiofrequency ablation
Eur Ann Otorhinolaryngol Head Neck Dis
(2012) - et al.
Electrical stimulation of the hypoglossal nerve in the treatment of obstructive sleep apnea
Sleep Med Rev
(2010)
Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis
Sleep Med Rev
Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea
Surgery
Epidemiology of obstructive sleep apnea: a population-based perspective
Expert Rev Respir Med
Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study
Sleep
Epidemiology of obstructive sleep apnea: a population health perspective
Am J Respir Crit Care Med
Obstructive sleep apnoea as a risk factor for stroke and death
N Engl J Med
Oral appliances for snoring and obstructive sleep apnea: a review
Sleep
Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea
J Clin Sleep Med
Upper airway surgery should not be the first line treatment for obstructive sleep apnoea in adults
BMJ
Effects and side-effects of surgery for snoring and obstructive sleep apnea – a systematic review
Sleep
Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence
Sleep
Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnoea revisited
Sleep
Surgery for obstructive sleep apnoea in adults
Cochrane Database Syst Rev
Clinical equipoise in sleep surgery: investigating clinical trial targets
Otolaryngol Head Neck Surg
Management of obstructive sleep apnoea/hypopnoea syndrome in adults: a national clinical guideline
Upper airway surgery does have a major role in the treatment of obstructive sleep apnea: “the tail of the dog.”
J Clin Sleep Med
Adherence to continuous positive airway pressure therapy: the challenge to effective treatment
Proc Am Thorac Soc
The nose, snoring and obstructive sleep apnoea
Rhinology
A clinical sign to predict difficult tracheal intubation: a prospective study
Can Anaesth Soc J
Diagnostic value of the Friedman tongue position and Mallampati classification for obstructive sleep apnea: a meta-analysis
Otolaryngol Head Neck Surg
Pulse oximetry: sufficient to diagnose severe obstructive sleep apnoea
Sleep Med
Assessment of obstruction level and selection of patients for obstructive sleep apnoea surgery: an evidence-based approach
J Laryngol Otol
Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea
Clin Otolaryngol
Sleep nasendoscopy: a 10-year retrospective audit study
Eur Arch Otorhinolaryngol
Oropharyngeal surgery for obstructive sleep apnoea in CPAP failures
Eur Arch Otorhinolaryngol
Nasal surgery for snoring in patients with obstructive sleep apnoea
Laryngoscope
Effect of nasal surgery on sleep-related breathing disorders
Laryngoscope
Pharyngeal morphology: a determinant of successful nasal surgery for sleep apnoea
Laryngoscope
Treatment of obstructive sleep apnea with nasal continuous positive airway pressure
Am Rev Respir Dis
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2018, Sleep Medicine ReviewsCitation Excerpt :Alternative treatments have the aim of correcting areas of collapse in the UA; either permanently via surgery, or just during sleep using oral application therapy (OAT). Various surgical techniques, such as palatal surgery, including uvulopalatopharyngoplasty (UPPP), which has been widely replaced by Laser-assisted uvulopalatoplasty (LAUP), radiofrequency interstitial thermal therapy (RFITT) to the soft palate, expansion sphincter pharyngoplasty (ESP), tonsillectomy, tongue base surgery, including transoral robotic surgery(TORS) techniques and laser epiglottoplasty have been described [12]. Surgery aims to address each level in which obstruction occurs.
Is transoral robotic surgery a safe and effective multilevel treatment for obstructive sleep apnoea in obese patients following failure of conventional treatment(s)?
2017, Annals of Medicine and SurgeryCitation Excerpt :Firstly, there is level I evidence to support CPAP as a highly effective (the ‘gold standard’) treatment for OSA – even at low levels of compliance [15]. Secondly, the results reported for the surgical treatment of OSA (in the pre-robotic surgery epoch) have been inconsistent and, as such, remain an area of intense debate [16]. This however is likely to be the result of poor patient selection combined with inability to address difficult-to-access areas due to ‘line-of-sight’ limitations associated with conventional transoral (microscopic and/or laser) surgery [2].
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The most important references are denoted by an asterisk.