Sleep apnea or obstructive sleep apnea is the most common sleep-related breathing disorder. Sleep apnea has a surprisingly high prevalence and it is serious public health issue. Muscles that control the airway relax during sleep, therefore the airway is narrowed. Normally it does not affect breathing but for some patients it causes snoring and difficulty breathing. Sometimes it may even pause breathing. If this syndrome is not treated it can disturb sleep with terrible physical and social consequences or even cause death. Moreover, it is associated with vascular risk factors and with significant cardiovascular morbidity and mortality.
The spectrum of options of sleep apnea treatment is very wide. These options include behavioural methods such as weight reduction, altering sleep position, postural conditioning, positive airway pressure devices and surgical approaches – upper airway modification, tracheostomy and even bariatric surgery. Choosing the best method or a combination of treatment options depends on etiological variability, in severity of the apnea, co-morbidity, and each patient’s opinion.
However, the gold standard treatment for adults with sleep apnea is positive airway pressure, which effectively prevents from upper airway collapse. Attention should be paid to mask, desensitization for claustrophobia and heated humidiﬁcation. Patient should be provided with education, regular follow-ups, compliant software and support groups. However, sleeping while wearing the positive airway device may cause difficulties and discomfort for a patient. That is why many patients prefer surgical intervention as it is often more effective and easier to cope with.
Upper airway surgery is one of the sleep apnea treatment options, used on the patients who do not tolerate positive airway pressure therapy or it is ineffective on them. Surgical treatment depends on the severity of the disease and symptoms. Usually, surgery is considered appropriate for patients with moderate to severe obstructive sleep apnea, strong daytime sleepiness, or signiﬁcant medical morbidities.
Surgery strives to eliminate sleep apnea symptoms without dependence on behavioural modification and mechanical devices. During surgical procedures anatomic abnormalities of the nose, palate, tongue, larynx, facial skeleton and the neck responsible for sleep apnea are eliminated and the upper airway is opened.
Surgical options to treat obstructive sleep apnea syndrome are:
- Nasal septoplasty and reconstruction
- Uvulopalatopharyngoglossoplasty (UPPGP)
- Laser-Assisted Uvulopalatoplasty (LAUP)
- Maxillomandibular Osteotomy (MMO)
- Others lower frequency operations
Currently, Uvulopalatopharyngoglossoplasty (UPPGP) is the most common surgical procedure used to treat obstructive sleep apnea. UPPGP includes resection of the uvula (small finger-shaped piece of tissue), distal margin of the soft palate, palatine tonsils, adenoids, and any excessive lateral tissue of the pharynx. The results suggest that the success rate of UPPGP is 66 % with careful preoperative selection of patients.
Laser-Assisted Uvulopalatoplasty (LAUP) is an alternative to UPPGP and it is a relatively new method. LAUP is less invasive, less morbid, cheaper, requires shorter recovery period and better tolerated. It is likely to be the most appropriate procedure for symptomatic snoring. When the region of the nose is correctly identified as the site of obstruction, surgical correction such as nasal septoplasty can effectively treat obstructive sleep apnea in a majority of patients.
Maxillomandibular Osteotomy (MMO) is very effective treatment of obstructive sleep apnea in patients with significant retrolingual airway obstruction with accompanying skeletal abnormalities. Moreover, it is usually applied when other surgical procedures do not help. Case series suggest that MMO has the highest surgical efficacy (86%). However, this method is often used as the last treatment option because it is painful, requires long recovery and often makes little changes to the facial appearance. During the surgery the upper (maxilla) and lower (mandible) jaws are moved forward, it effectively enlarges the airway in both the palate and tongue regions and limits posterior collapse during sleep.
Tracheostomy is yet another method used to treat obstructive sleep apnea. However, it is hardly accessible to the non-severe patients. Nonetheless, tracheostomy sometimes is the only lifesaving treatment option for patients with severe obstructive sleep apnea and associated cardiovascular problems.
Bariatric surgery such as gastric bypass or gastric sleeve is one of the options to treat sleep apnea as well. Usually one of the causes of this condition is obesity. In this case weight loss surgery can help a patient to reduce his or her weight, increase physical activity, and eliminate sleep apnea.
Successful surgery outcomes strongly depend on appropriate patient selection, correct procedure selection and experience of the surgeon. Overall evaluation and proper surgical treatment can result in successful long-term clinical outcome. Most surgeries are done in combination and in a multistep manner. Although like in any other surgeries it is impossible to avoid risks, surgical treatment remains an important therapeutic consideration in all patients with obstructive sleep apnea.