Surgery may be needed to correct a sleep disorder, particularly to correct obstructive sleep apnea (OSA). In some cases, surgery can also be done to correct abnormal snoring and severe nasal obstructions in people who suffer from insomnia.
Sleep apnea is diagnosed when a person has both airway blockage and symptoms of disrupted sleep or medical complications. Airway blockage may be due to an obstruction in the upper part of the throat, the lower part of the throat, or a combined upper and lower throat obstruction.
- In the upper throat, the structures that may contribute to sleep apnea include a long and thickened soft palate, a large swollen uvula, narrow width and depth, a bulge from an enlargement of muscle in the throat, and redundant (excess) folds in the mucous membrane.
- In the lower throat, obstructions may occur in the tongue, tonsils and redundant (excess) tissues of the upper voice box.
- Abnormal facial formations (e.g., a recessed jaw) and obesity also may cause airway obstruction and sleep apnea.
Some people with sleep apnea can be treated without surgery. They may have an underlying medical condition (e.g., heart failure or obesity) that may be causing sleep apnea. (This is called central sleep apnea vs. obstructive sleep apnea.) Treating the condition may give them relief. For obese patients, bariatric surgery (gastric bypass surgery) may be discussed as an option to lose weight and reduce the symptoms of sleep apnea. In other cases, some people find relief by using an oral appliance or a continuous positive airway pressure (CPAP) device during sleep.
Surgery may be recommended when other treatments do not work, or it may augment other sleep disorder therapies. Surgery is performed for people with:
- Lesions (abnormalities) of the upper airway tissue
- Apnea that has failed medical treatment
- A lifestyle that precludes other treatments for obstructive sleep apnea
- Habitual snoring in the absence of obstructive sleep apnea
The decision to perform surgery is based on the location of the collapsed tissue, the severity of the disease, associated medical risk and the likelihood of success. No single surgical procedure will work for all people.
The goal of surgery is to stabilize the upper airway by modifying its size or shape and reducing the amount of collapsible tissue in the throat to prevent collapse and obstruction. This includes removing any obstructions in the throat such as growths, polyps, or enlarged adenoids and tonsils. Oral and maxillofacial surgery may be needed to correct abnormal facial structures, such as a recessed jaw.
Surgery to correct obstructive sleep apnea is usually covered by health insurance. Please check with your health insurance provider to determine your coverage.
Types of Surgery
There are many types of surgery to correct obstructive sleep apnea (OSA).
Nasal surgery. This procedure is done for obstructive sleep apnea with nasal blockage. Nasal surgery is performed for mild apnea or snoring when no other structural or functional problem is identified. It may improve CPAP tolerance in patients with marked nasal blockage, and also may improve the success of other surgeries for obstructive sleep apnea.
Uvulopalatopharyngoplasty (UPPP). This procedure involves removing the uvula, a portion of the soft palate, the tonsils, and redundant (excess) tissue from the throat. This procedure is done for people with obstruction in the upper pharynx of the palate. UPPP may be performed in conjunction with other treatments targeted at other areas of collapse.
Hyoid myotomy. This procedure involves pulling the hyoid bone forward to help open the airway. The hyoid bone is a small C-shaped bone in the upper neck above the Adam’s apple cartilage. Many muscles of the tongue and throat attach to the hyoid. In the procedure, the hyoid bone is exposed in the neck. The muscles are separated and a small mid-portion of the bone is exposed. The hyoid bone is then pulled forward to the lower jaw. This procedure, which may be best for people who have major obstruction at the epiglottis and lower tongue base, is often performed with other surgeries.
Mandibular (lower jaw) advancement. This procedure moves the bone, soft tissue and muscles of the jaw forward to enlarge the airway. The amount of advancement may be limited by the natural position of the teeth. People with a backward positioning of the teeth and jaw may benefit from lower jaw advancement alone.
Bimaxillary (upper and lower jaw) advancement. This procedure is done for people with significant jaw deficiency, morbid obesity, and those with obstructive sleep apnea who have failed more conservative treatments. The procedure involves cutting the bones of the upper and lower jaws and lengthening them a small amount. The tongue and the palate are pulled forward, enlarging the airway. The surgery also enlarges the mouth to provide more room for the tongue. Both jaws are advanced together, retaining the person’s bite. The surgery is performed through incisions inside the mouth.
Other procedures, such as partial glossectomy (removal of part of the tongue), genioglossus advancement (advancement of muscles in the jaw that depress and protrude the tongue) and palatopharyngoplasty (removal of unnecessary palate and throat tissue) are also often required. These are usually performed initially, followed by jaw advancement at a later stage.
Limited mandibular osteotomy (cutting the jaw bone) and genioglossus advancement. The genioglossus muscle attaches the base of the tongue to the inside front of the jaw bone. This muscle determines the position and collapsibility of the tongue. In people with obstructive sleep apnea, the genioglossus is more active in holding the airway open at rest. Genioglossus advancement detaches the part of the jaw bone where the muscle attaches and moves the tongue forward to enlarge the airway.
Procedures for Obstruction of the Lower Throat
The following procedures modify tissues of the lower pharynx when the involved tissues are obstructive or abnormal:
Epiglottidectomy lingual tonsillectomy. This procedure is done to remove the tonsils and all or part of the epiglottis to correct lingual tonsillar hypertrophy (enlargement of the tonsils near the base of the tongue).
Midline glossectomy (MLG). This procedure involves a partial removal of the base of the tongue to enlarge the lower pharyngeal airway.
Lingualplasty. Lingualplasty — a more aggressive removal of tongue tissue — may be done for people with severe obstructive sleep apnea syndrome following UPPP failure. This procedure has a 70 percent short-term success rate in reducing a person’s respiratory disturbance index (RDI) to less than 20 events per hour. Lingualplasty is performed in patients with disproportionate tongue base size and/or excessive tongue size.
Both midline glossectomy and lingualplasty are performed in patients with more severe obstructive problems. Airway support — tracheotomy or continuous positive airway pressure (CPAP) — during surgery is crucial.
In some patients, excision of a redundant epiglottis and redundant supraglotic tissue may be required to successfully treat obstructive sleep apnea. The epiglottis is the structure at the root of the tongue that folds over the glottis, preventing food and liquids from entering the trachea during swallowing. Supraglotic refers to tissue situated above the glottis. Selection of this treatment is based on finding supraglottic tissues obstructing the airway.
Tracheotomy. A tracheotomy is a surgical “hole” from the skin of the neck to the windpipe below the voice box. A tracheotomy is done for people with severe obstructive sleep apnea and those who are not candidates for other therapies. Because the hole bypasses the throat, blockage does not occur during sleep. Tracheotomy is very successful in the treatment of apnea and its complications. Since the upper airway is open during wakefulness, after healing, the tracheotomy hole may be closed except during sleep.
Despite the benefits of tracheotomy, the psychosocial implications, risks of infection and other potential complications may make it unacceptable for many patients. In patients who accept a tracheotomy, there is a reduction in the incidents and mortality associated with sleep apnea.
Procedures for Snoring
The following are procedures that can be done to alleviate excessive snoring that interrupts sleep patterns.
Uvulopalatoplasty (UP). This surgery, for treatment for benign snoring, is commonly done as a laser-assisted procedure. It involves removing tissue of the soft palate and the uvula under local and topical anesthesia in an outpatient setting. The soft palate is “sculpted” by creating “trenches” around the uvula and reshaping the uvula. This procedure may be repeated until the desired outcome is achieved.
Nasal surgery. This is done for mild obstructive sleep apnea with nasal blockage or snoring when no other structural or functional problem is identified. It may improve CPAP tolerance in patients with marked nasal blockage, and may improve the success of other surgeries for obstructive sleep apnea.