Surgery (of any type) where anaesthesia is used, poses a very real danger to people suffering from Sleep Apnoea. In all cases your surgeon and anaesthetist should be informed (in advance) if you suffer from sleep Apnoea. You also need to inform your sleep specialist of any impending surgery, as they will send medical data to your surgeon. If using CPAP you will probably be advised to bring your machine to hospital and possibly to theatre. It may be required during the post operative recovery period.
Surgery for Sleep Apnoea: The goal of surgery is to enlarge the airway and prevent snoring and airway collapse. Surgery is site specific (to enlarge a specific portion of airway). Due to the risks associated with anaesthesia or an operation surgery should NOT be considered as a first option. There is also risk that surgery may cure snoring, but if the patient has Apnoea, one of the primary symptoms will have been removed while the Apnoea remains and may go undiagnosed while further damage is being done to the respiratory and cardiovascular systems possibly leading to a stroke (which may have been avoided). We are unable to source reliable figures for success/failure with surgery. In general, with the exception of tracheotomy (see below) surgery for “curing” Apnoea is not successful and is quite painful. In Europe surgery is seldom used to treat/cure Apnoea. In America an increasing number of ENT (Ear, Nose and Throat) surgeons continue to pioneer this method of treatment and now offer a “cocktail” of surgical procedures over a period of two to four years. In some cases “success” has been claimed, however they are usually short lived as symptoms of Apnoea start to reappear within a short space of time. There are no “quick fixes” for Sleep apnoea. The following is a list of all the known surgical procedures currently in use to treat/cure Apnoea. There are no reliable figures available for the success or failure of any one procedure. The best estimates for UPP surgery is a”50% improvement in 50% of cases”. Unfortunately for anyone with mild to severe Apnoea this means that CPAP must still be used after the operation.
Septoplasty: The septum is the divider between the two nasal passages. A deviated (crooked) septum may obstruct the nasal airway. A Septoplasty is performed through the nostrils. The cartilage and bone of the septum is straightened.
Turbinate Reduction: The turbinates within the nose are made of bone surrounded by soft tissue whose functions are to warm and moisten the air as you breathe. There are three turbinates in each nostril (lowest, middle and upper). Reduction of the size of an enlarged turbinate can improve the size of the nasal airway. Turbinate reduction may be performed with surgical instruments, lasers, radio frequency or cauterisation. Removal of polyps Nasal polyps can obstruct the nasal airway. Removal of polyps can “free up” the airway. Sinus Surgery Sinus infection can contribute to nasal obstruction and surgery may be necessary.
Upper Airway Surgery
Uvulopalatopharyngoplasty (UPPP) surgery: The surgery removes the uvula the lower edge of the soft palate is trimmed. If present, the tonsils are generally removed and the tissues around them trimmed. It can be done separately or in conjunction with other treatments, depending on where the airway obstructions occur. There are the usual surgical risks involved with surgery. Notable ones are general anaesthetic (depresses breathing reflex and can be risky in people with breathing problems like Apnoea), swelling of the airway, need for pre and post-operative medication (can depress the breathing reflex), bleeding, and significant pain lasting several weeks.
Is it effective? Will it free me from having to wear a CPAP machine for life?: This surgery seems to have a history of being effective in 50% of patients 50% of the time. In other words many of the people who have UPPP will end up having to use CPAP anyway. It is almost never a “cure all”. The risks and side effects of surgery are usually not worth it. This is a decision that each person has to make, but you should give it a great deal of thought beforehand. Surgery is not something to be undergone on a whim, and certainly not for the sole reason of ridding yourself of CPAP. The vast majority of people who have undergone UPPP for the treatment of Obstructive Sleep Apnoea do have to continue using CPAP. UPPP is seldom, if ever, used for treating OSAS in the UK or Eire.
Laser assisted Uvulopalatopharyngoplasty (LAUP): LAUP is a relatively new laser surgery on the uvula and soft palate that is reduced to diminish snoring, but no controlled studies have been done to show that it reduces apnoea. As it is less extensive than UPPP, it is unlikely to be more effective in treating apnoea. It is usually done in several steps, and is an outpatient procedure. For that reason it is less risky than UPPP. While the procedure may sometimes be effective in helping people who snore but do not have apnoea, the main danger from LAUP is that people may eliminate their snoring and assume their problems are solved, when in fact they may still have untreated sleep apnoea which may continue to get worse but be ignored because its primary alarm signal (snoring) has been silenced. Potential patients should be careful that they don’t see an “ad” in the paper, call the doctor, and rush into an LAUP procedure without research and consideration.
Somnoplasty (Radio-frequency Tissue Ablation of Palate): Deliverance of Radio frequency waves by a needle electrode to the underside of the soft palate to cause contraction of excessive tissues that cause snoring. This procedure involves a progressive shrinkage of the soft palate and uvula. Usually patients require up to four treatment sessions of 15/20 minutes under local anaesthesia. This procedure is relatively painless.
Tonsillectomy and Adenoidectomy: Tonsils are tissues on the sides of the upper throat and if enlarged may narrow the width of the upper airway. Adenoids are at the back of the nose and can obstruct the nasal airway. This surgery is most common in children as adenoids usually shrink with age.
Lower Airway Surgery
Genioglossus Advancement: The Genioglossus muscle attaches from the back of the tongue to a spot on the back of the chin. This surgery attempts to pull the back of the tongue forward in an effort to enlarge the airspace behind the tongue. The procedure pulls forward a rectangular or circular segment of chin bone (below the four front teeth) and hols it in place with a plate or screw. A minimal change in the appearance of the chin results.
Hyoid Advancement: The Hyoid bone is just above the Adam’s apple. This bone is move forward and either attached to the Adam’s apple or jaw bone. The purpose is to enlarge the space behind the tongue.
Midline Glossectomy, Lingualplasty, and Lingual Tonsillectomy: Midline Glossectomy involves a reduction in size of the tongue (if enlarged). The back of the tongue is reduced in size by excising a V shaped portion of the centre part of the tongue. Lingualplasty is a more aggressive resection with additional removal of side wedges. Lingual Tonsillectomy involves the removal of the tonsil like tissue on the back part of the tongue; it may also be performed with a laser. A temporary tracheotomy is usually performed with these procedures to avoid breathing difficulties that might arise from temporary swelling. The purpose is to reduce the size of the tongue thereby increasing the air space behind the tongue.
Bimaxillary Advancement (Lafort 1 Maxillary Osteotomy with Bilateral Sagittal split Mandibular Osteotomy): The upper and lower jaw bones are moved forward along with all the teeth in an effort to pull soft tissue structures forward and make more room for the tongue. Metal plates and screws are used to hold the realigned jaw in place. Orthodontic work prior to or following the procedure may be necessary in order to maintain the proper alignment of the teeth. Change in facial appearance relates to the extent of the advancement. Tongue Suspension Suture (Repose) The tongue is pulled forward by way of a permanent stitch to a screw which has been placed through the back of the tongue. This is to prevent the tongue falling back during sleep and obstructing the airway.
Surgical Bypass of the Airway
Tracheostomy: An opening is made at the front of the neck to the windpipe and a plastic or metal tube is inserted. During sleep the patient breathes through the tube, while during the day it is covered to allow normal breathing and speech. There are considerable hygiene problems with this procedure.