NOSE, PALATE, TONGUE BASE: Surgery for Obstructive Sleep Apnea

Megan Durr, MD

Surgery is an option for treatment of obstructive sleep apnea (OSA) when less invasive medical treatment options provide insufficient results or are not tolerated. For years, many people considered sleep surgery to be synonymous with one specific procedure called uvulopalatopharyngoplasty (UPPP), which removes soft palate tissue (roof of the mouth) and the tonsils.

With experience and extensive research, sleep surgeons have learned that the surgical treatment of OSA requires much more than UPPP. We now know that the cause of obstruction varies significantly among patients with OSA and that successful surgery relies on the accurate identification of factors responsible for obstruction in each patient. This critical information allows the sleep surgeon to develop a treatment plan that targets the identified area(s) of obstruction, thereby improving surgical outcomes.

Many surgical options are available for treating OSA. These procedures enlarge and/or stabilize structures of the airway to prevent collapse during sleep. The procedures are organized into the three main locations that contribute to obstruction: nose, palate and tongue base. Most patients with OSA have more than one of these areas contributing to their obstruction.

Nasal Procedures
Nasal obstruction can interfere with nasal breathing and lead to snoring and OSA. Nasal procedures do not generally “cure” OSA, but rather help patients with nasal obstruction better tolerate continuous positive airway pressure (CPAP). Nasal procedures are rarely performed alone for OSA, but they are often used in conjunction with palate or tongue-base procedures.

Nasal procedures include turbinate surgery, septoplasty, sinus surgery, rhinoplasty and nasal valve surgery. The inferior turbinates are normal outgrowths from the nasal side wall into the nasal cavity, and they can become enlarged in response to nasal allergies and inflammation. Reducing the size of the inferior turbinates helps open the nasal airway and relieve obstruction.

Septal deviation is another common cause of nasal obstruction. The nasal septum separates the two nasal cavities and can be thickened or deviated toward one side, causing obstruction on that side. Septoplasty aims to straighten the septum by removing areas of septal deviation. Sinus surgery is also an option for patients with chronic or recurring sinusitis.

The visible external portion of the nose also plays an important role in nasal breathing. The nasal side walls can collapse during breathing and cause obstruction of the nasal airway. Rhinoplasty and/or nasal valve surgery is aimed at treating obstruction that originates in the external nose.

Most nasal procedures are performed under general anesthesia as an outpatient surgery. The risks of nasal surgery vary among procedures but can include nose bleeds, infection, change in appearance of the nose, and nasal dryness or crusting.

Upper Throat Procedures
Obstruction at the level of the soft palate and tonsils plays a major role in OSA, and many surgical procedures have been developed for this type of obstruction. They range from in-office procedures to surgeries under general anesthesia. In-office procedures, such as soft palate radiofrequency ablation and the Pillar Procedure, are performed under local anesthesia and can be helpful for people with snoring or mild OSA.

Soft palate procedures include UPPP, expansion sphincter pharyngoplasty, uvulopalatal flap and lateral pharyngoplasty. UPPP is the most common procedure, and it involves removing the tonsils, uvula and part of the soft palate. The other procedures are modifications of UPPP involving removal and repositioning of the muscles and/or soft tissue of the palate area to target the specific site of obstruction. Many of these modified procedures have better outcomes than UPPP when they are based on the surgeon’s pre-operative airway exam and targeted to the individual patient.

Palate procedures are usually performed in the operating room under general anesthesia, and most require an overnight stay in the hospital. The recovery period includes two weeks of throat pain as well as diet and activity limitations. The main risks of these surgeries include bleeding, swallowing problems and speech changes.

Lower Throat Procedures
Most patients with OSA will have some level of collapse in the area of the tongue base. The muscles of the tongue relax during sleep, which leads to obstruction of the airway. Despite the high percentage of patients with airway collapse at the base of the tongue, studies have shown that only a small percent of sleep surgeries done in the United States include tongue-base procedures. This finding indicates that many patients who could benefit from tongue-base procedures are not receiving surgical interventions in this area.

Tongue-base procedures include lingual tonsillectomy, midline glossectomy, tongue radiofrequency, genioglossus advancement and epiglottis surgery. The lingual tonsils are different from the tonsils that can be seen by looking into the mouth. The lingual tonsils are tonsil tissue located in the back of the tongue that can be enlarged, contributing to airway obstruction. Lingual tonsillectomy involves removing the lingual tonsils through the mouth under general anesthesia. The midline glossectomy is performed in a similar fashion but removes a portion of the tongue muscle in addition to the lingual tonsils.

Radiofrequency treatment of the tongue is performed in the operating room or clinic using a probe that applies radiofrequency to four areas of the tongue, causing the tongue to shrink and stiffen, thereby decreasing the amount of collapse during sleep. The genioglossus advancement procedure is performed in the operating room via an incision in the lower lip. A rectangular piece of the jaw bone is excised and advanced forward, capturing the attachment of the genioglossus muscle—the largest muscle of the tongue—and pulling this forward as well.

Maxillomandibular Advancement
Another surgical option for OSA is maxillomandibular advancement, which involves moving the upper and lower jaw forward to enlarge the airway at the level of the upper and lower throat. Compared to the other procedures mentioned, it often provides the most improvement in OSA but is the most invasive and has the longest recovery period. This procedure is generally performed after insufficient improvement from prior sleep surgeries or for patients with jaw abnormalities contributing to airway obstruction.

Conclusion
There have been many recent advances in the surgical treatment of OSA. Several surgical options are available, and outcomes can be improved by personalizing the treatment plan to each patient. The treatment plan should be discussed with a specialized sleep surgeon and designed based on a thorough pre-operative evaluation of the airway with the goal of achieving the best result with the lowest risk.

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Dr. Durr is a head and neck surgeon at Kaiser Permanente Oakland.
Email: megan.durr@kp.org