Minimally Invasive Surgical Treatments for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is recognized primarily as a problem of the upper airway. Although narrowing or actual obstruction of the airway during the night can be found in only 1 or 2 areas of the upper airway, most often sleep apnea involves the entire pharyngeal upper airway passages. Three regions are considered to be of major concern: the nasal cavity region, the retropalatal region, and the retrolingual region. As the level of these 3 regions descends, the volume of tissue from the nose to the base of the tongue increases significantly. This leads to increased difficulty treating OSA with each descending region as well as to a lower success rate overall. Sometimes, the problem causing OSA is limited to only 1 region but may involve 2 or even all 3 regions.¹

Continuous positive airway pressure (CPAP) therapy and other positive airway pressure (PAP) therapies have been considered a safe and effective treatment for OSA. Unfortunately, compliance rates, even among patients who use it to successfully eliminate their symptoms, can vary from 50% to 70%. Complaints about using CPAP and other PAP therapies range from skin irritation, discomfort to the nose or nasal passages, and eye problems to claustrophobia from wearing a mask. Patients who are unable or unwilling to use CPAP therapy can be candidates for surgical treatment of OSA.²

This article discusses surgical options for adult patients who have OSA who choose not to use CPAP therapy, the reasons to perform surgery for adults who have OSA, and the desired outcomes of surgery for OSA with a focus on minimally invasive procedures. Interventions for pediatric patients are not addressed.

Treatment Options

Treatments other than CPAP can help lessen the severity of OSA. Noninvasive treatments include weight loss, positional treatment (avoiding sleeping on one’s back), and oral appliances. Practice parameters from the American Academy of Sleep Medicine (AASM) for the treatment of OSA include dietary weight loss in addition to the primary therapy. An improvement in the apnea-hypopnea index (AHI) may occur with dietary weight loss.³

Major weight loss through the use of bariatric surgery has been shown to be effective in treating OSA and obesity hypoventilation syndrome (OHS), which is defined as daytime hypercapnia and hypoxemia (PaCO₂ > 45 mm Hg and PaO₂ < 70 mm Hg at sea level) in an obese patient (body mass index [BMI] > 30 kg/m²) with sleep-disordered breathing in the absence of any other cause of hypoventilation.⁴ Some individuals may have both conditions. However, CPAP therapy should not be discontinued even when major weight loss occurs until repeat polysomnography has been performed. Major weight loss may cure OHS and help improve the severity of OSA but will not totally resolve the condition.⁴ According to Woodson, sleep apnea in patients who are morbidly obese may be different from traditional OSA as rapid eye movement (REM), REM-related apneas, and hypoventilation occur more often in this population. Although weight loss is strongly recommended for patients with OSA, bariatric surgery is not recommended as the sole treatment for traditional OSA.⁵

Positional therapy, wherein the patient avoids the supine position, can be effective as a secondary or supplemental therapy in addition to treatment with CPAP. Guidelines recommend this primarily for individuals who have a lower AHI when in the nonsupine position than when lying on their backs. Patients who benefit from positional therapy tend to be younger, less obese, and with a less severe condition. The AASM practice parameter was based on 3 level II studies—randomized trials with high alpha and beta levels.⁶ One of the level II studies compared supine with an upright position, stating: “Because not all patients normalize AHI when non-supine, the committee’s opinion is that correction of OSA by position should be documented with an appropriate test.” Special pillows have been described in 2 papers reviewed by AASM, which seemed to improve OSA.⁶

The AASM guidelines state that oral appliances are indicated for some patients, although they are not as efficacious in treating OSA as CPAP therapy. Oral appliances are recommended for patients with mild to moderate OSA who have not responded to CPAP therapy, cannot tolerate CPAP therapy, are not appropriate for treatment with CPAP for some reason, or fail treatment with CPAP along with other behavioral measures, such as weight loss or positional therapy.⁶

In addition, the AASM guidelines recommend that patients with severe OSA, “should have an initial trial of nasal CPAP because greater effectiveness has been shown with this intervention than with the use of oral appliances. Upper airway surgery (including tonsillectomy and adenoidectomy, craniofacial operations, and tracheostomy) may also supersede use of oral appliances in patients for whom these operations are predicted to be highly effective in treating sleep apnea.”⁶