Surgical Management of Obstructive Sleep Apnea

Indications for Surgery (Box 15.6)

• AHI >5 and <14 with symptoms or comorbidities
• AHI >15
• Oxyhemoglobin desaturation <90%
• Upper airway resistance syndrome (with objective neurocognitive impairment unresponsive to medical therapy)
• Significant cardiac arrhythmias associated with obstruction
• Unsuccessful or refused medical therapy with patient desire for surgery
• Patient medically stable enough to undergo the recommended procedure

Preoperative Principles

• A staged, stepwise surgical protocol is used. The site of obstruction must be identified in every patient before choosing the procedure.
• Drug-Induced Sleep Endoscopy (DISE) is the optimal method to evaluate airway collapse patterns. In one series, DISE altered the surgical plan in 62% of patients, and 73% had multilevel obstruction.
• Endoscopic studies show that ~100% of OSA patients have retropalatal obstruction, and ~77% have retroglossal obstruction - meaning most patients require multilevel surgical treatment.
• Patients with isolated palatal collapse undergo palatal surgery; those with tongue-base obstruction undergo hypopharyngeal procedures.
• Anesthesia planning is mandatory: use oropharyngeal airway, avoid paralyzing agents until mask ventilation is confirmed, and prepare alternative airway methods. Discuss the possibility of tracheotomy with the patient preoperatively.
• Patients must be screened for cardiovascular disease before surgery.

Surgical Treatment Options (Box 15.7)

1. Nasal Surgery

• Nasal obstruction is associated with poor sleep quality, snoring, and OSA.
• Nasal surgery alone is unlikely to significantly improve AHI but restores physiologic nasal breathing and, critically, improves CPAP adherence in patients who previously could not tolerate nasal CPAP.
• Nasal surgery should be considered as an initial step in OSA management primarily to facilitate CPAP use.

2. Palatal Surgery

Uvulopalatopharyngoplasty (UPPP)

• First described by Fujita et al. in 1981 - the most commonly performed surgical procedure for OSA.
• Involves resection of redundant palatal and pharyngeal tissue along with tonsillectomy.
• When used indiscriminately regardless of obesity, retrognathia, or multilevel obstruction, it is often unsuccessful.
• Success rate is markedly dependent on the site of collapse: meta-analyses show success rates of ~52-80% in properly selected patients with isolated palatal obstruction, but much lower in unselected cohorts.
• In patients with non-palatal (lateral wall) collapse patterns identified on DISE, outcomes are worse.

Z-Palatoplasty

• A modification of UPPP that directs the pull on the soft palate in an anterolateral direction, widening the retropalatal space (see Fig. 15.15).
• Designed to address lateral pharyngeal wall collapse in addition to palatal collapse.

Expansion Sphincter Pharyngoplasty (ESP)

• Specifically targets lateral pharyngeal wall collapse (circumferential or lateral pattern on DISE).
• The palatopharyngeus muscle is repositioned laterally and superiorly to expand the velopharyngeal inlet.

Transpalatal Advancement Pharyngoplasty

• Used for select patients, particularly where UPPP is insufficient.

Palatal Radiofrequency Ablation, Pillar Implants, Injection Snoreplasty

• Less invasive options primarily for snoring and mild OSA; generally not sufficient as standalone treatments for moderate-to-severe OSA.

3. Hypopharyngeal / Tongue-Base Surgery

Lingual Tonsillectomy

• Addressed when lingual tonsillar hypertrophy contributes to tongue-base obstruction.

Partial Midline Glossectomy

• Reduces tongue-base volume to improve the retrolingual airway.

Tongue-Base Radiofrequency Ablation

• Delivers radiofrequency energy to the base of tongue to reduce tissue volume via submucosal scarring and contraction.
• Can be performed in staged sessions; generally reserved for mild-to-moderate disease or as adjunct treatment.

Tongue-Suspension Suture

• A suture is passed through the base of tongue and anchored to the mandible to prevent posterior tongue displacement during sleep.

Genioglossus Advancement (Mandibular Osteotomy + Genioglossal Advancement)

• A rectangular osteotomy of the anterior mandible is performed at the geniotubercle to advance the genioglossus muscle attachment anteriorly.
• This tensions the genioglossus, reducing tongue-base obstruction.
• Often combined with UPPP as part of the Riley-Powell-Stanford Phase I protocol.

Hyoid Myotomy and Suspension

• The hyoid bone is released from its attachments (myotomy) and suspended anteriorly to the mandible or thyroid cartilage.
• Expands the hypopharyngeal airway by pulling the tongue base and epiglottis anteriorly.
• Typically combined with other procedures rather than performed alone.

Maxillomandibular Advancement (MMA)

• The most anatomically effective surgical procedure for OSA.
• Both the maxilla and mandible are advanced using Le Fort I osteotomy + bilateral sagittal split ramus osteotomy, typically by 10 mm or more.
• Advancement expands the entire upper airway (retropalatal + retrolingual) by pulling all attached pharyngeal soft tissues anteriorly.
• Meta-analyses show surgical success rates of ~86% and cure rates of ~43%, making it the most effective single surgical procedure.
• Reserved for patients who fail Phase I surgery or those with significant dentofacial/skeletal abnormalities.
• Requires orthognathic planning and carries risks of facial numbness, malocclusion, and prolonged recovery.

4. Hypoglossal Nerve Stimulation (Upper Airway Stimulation)

• Implantable device (e.g., Inspire system - STAR trial) that senses inspiratory effort via a chest wall pressure sensor and delivers timed electrical stimulation to the hypoglossal nerve, increasing genioglossus tone during each inspiration.
• STAR trial (2014): Multicenter prospective trial; demonstrated significant reduction in AHI and improvement in oxygen desaturation index with sustained benefit at 12 months.
• Patient selection criteria: BMI <32 kg/m², AHI 25-65 (moderate-to-severe but not morbidly elevated), non-concentric collapse on DISE (i.e., no complete circumferential velum collapse). AHI ≤50 + BMI ≤32 kg/m² predicts best outcomes.
• In the Van de Heyning series, the success rate was 55% in appropriately selected patients vs. 0% in those who did not meet criteria.
• Advantage: minimally invasive, avoids oropharyngeal scarring, adjustable, reversible.

5. Tracheotomy

• Described at line 1578 of block 4 as a definitive treatment option.
• Bypasses the entire upper airway obstruction and is effectively 100% curative for OSA from upper airway collapse.
• Reserved for patients with severe, life-threatening OSA who have failed all other treatments, or those with complex craniofacial anomalies.
• Carries significant quality-of-life and social concerns.
• Should be discussed with patients preoperatively as a possibility in any airway surgery.

Postoperative Care

• Hospitalization is recommended for most patients after airway surgery.
• ICU admission should be considered for multilevel surgery.
• Nasal CPAP is recommended for the first 2 weeks postoperatively (especially in severe OSA, where the lowest preoperative SpO2 may be as low as 51.5%).
• Follow-up PSG at 3-4 months is recommended to objectively evaluate surgical response.

Surgical Algorithm Summary

• Cummings Otolaryngology Head and Neck Surgery, Chapter 15 (Sleep Apnea and Sleep Disorders), pp. 305-320

Surgical Diagrams for OSA - from Cummings

1. Modified Mallampati / Friedman Staging - Patient Selection for UPPP

• Grade I - Entire uvula + tonsils visible → UPPP success ~80%
• Grade II - Partial uvula visible → UPPP success ~40%
• Grade III - Only soft + hard palate seen (no uvula) → UPPP success ~8%
• Grade IV - Only hard palate seen

Combined with tonsil size and BMI = Friedman staging for UPPP patient selection

2. Z-Palatoplasty (Soft Palate Anterolateral Repositioning)

• Draw soft palate (dome shape, viewed from above/behind)
• Show bilateral incisions on either side forming a Z-pattern
• Draw bilateral suture lines curving anterolaterally (arrows pointing up-and-outward)
• The key point: vectors of pull are anterolateral, not just posterior - this widens the retropalatal space by pulling the soft palate forward and to the sides, not just tightening it posteriorly
• Label: "Widened retropalatal space" in the center

3. Expansion Sphincter Pharyngoplasty (ESP)

• A - Normal oropharynx with tonsils in fossa
• B - Tonsillectomy done; palatopharyngeus (vertical muscle) exposed
• C - Palatopharyngeus elevated off posterior pillar
• D - Muscle rotated superolaterally toward the hamulus
• E - Suture suspension anchoring the muscle to the hamulus → pharyngeal inlet widened laterally

Key label: "Lateral pharyngeal wall expansion" - specifically targets circumferential/lateral collapse pattern on DISE

4. Genioglossal Advancement - Rectangular Geniotubercle Osteotomy

• Draw the mandible (horseshoe shape, anterior view)
• Mark a rectangular box at the midline symphysis (the geniotubercle)
• Show the fragment being rotated outward (anteriorly) - the fragment is turned 90° to create bony overlap
• Fix with a single inferior miniscrew
• Label: "Genioglossus muscle attachment advanced anteriorly" → tensions the tongue base → prevents posterior displacement during sleep

Draw lateral view too: show tongue being pulled forward by the tensioned muscle

5. Hyoid Myotomy and Suspension

• Draw hyoid bone (U-shaped) with infrahyoid muscles attaching below
• Show downward arrows from mandible onto hyoid (compressing) and upward arrows from thyroid cartilage
• The hyoid is released from its muscular attachments (myotomy) - draw dotted cut lines through the infrahyoid muscles below the hyoid

• Show hyoid being suspended superiorly with sutures (draw suture loops passing through hyoid body)
• Anchor sutures pass to the inferior mandible (hyoid-to-mandible) or thyroid cartilage (hyoidthyroidopexy)
• Result: entire tongue base and epiglottis pulled anteriorly, expanding the hypopharyngeal airway

6. Maxillomandibular Advancement (MMA)

• Draw lateral skull profile
• Draw Le Fort I line (horizontal cut through maxilla above the teeth)
• Draw bilateral sagittal split line through the mandibular ramus
• Show both jaws advanced at least 10 mm anteriorly with arrows
• Show rigid plate fixation (miniplates + screws) at both osteotomy sites
• Optional: show previous genioglossal advancement screw at symphysis
• Draw a before/after airway outline: narrow posterior airspace → widened airspace after advancement
• Label: "All attached pharyngeal soft tissues pulled forward en bloc"

Most effective surgical procedure for OSA - success rate ~86%

Quick Reference: Which Diagram to Draw for Which Question