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A surgical intervention is an important consideration when continuous positive airway pressure (CPAP) therapy fails or is not tolerated. CPAP therapy is still considered first-line treatment for Obstructive Sleep Apnea (OSA), but adherence among patients is about 30 to 50 percent, which increases risk factors for serious, sometimes deadly cardiovascular and neurological problems associated with untreated apnea.
Knowing when surgery is the right decision and which procedures will give patients the best outcomes will be life-changing for millions of Americans suffering with sleep-disordered breathing. This guide will provide the surgical landscape of sleep apnea based on both research and expert opinion.
Sleep apnea surgery is generally indicated as second-line treatment after conservative treatment options have failed. Most experts recommend trying CPAP therapy first, as it's been shown to be effective as the first-line treatment option, and the risks are low.
The primary indications for surgery may include:
We asked Dr. Michael Grandner, Sleep Expert and Professor of Neuroscience and Physiological Sciences, about the timing for surgery. He states: "When CPAP adherence is persistently not successful, despite appropriate fitting and support, consideration for surgery is warranted." This philosophy guarantees that patients are given every opportunity for first-line therapies before proceeding with surgical options that are more invasive and carry the inherent risks associated with surgical procedures.
Uvulopalatopharyngoplasty is still the most common surgery option performed for OSA, involving removal or alteration of the soft tissue in the throat to avoid airway obstruction.
Key Features of the Procedure: UPPP involves removing tissue from the uvula, soft palate, and lateral pharyngeal walls. Modified procedures lean toward repositioning tissue rather than removal-only procedures to limit complications while maximizing treatment success.
Outcomes: UPPP has been reported to have up to 66% success if patients are carefully selected in the preoperative phase. It should be noted that success varies depending on anatomical and procedural variations. Approximately half of patients will report fewer significant apneic events after UPPP, although complete resolution of symptoms is rare.
Ideal Patient Selection: Candidates for UPPP have predominantly soft palate obstructions. Using fiberoptic pharyngoscopy, cephalometric roentgenography, and CT scans are tools to narrow ideal candidates based on evidence of the level of obstruction.
Long-term Outcomes: Modified UPPP outcomes have at least 8 years documented efficacy. They concluded that the mean AHI was reduced by 14.0 events/hour; however, over time, effectiveness diminished. Those with elevated BMI noted lower long-term outcomes, demonstrating the importance of managing weight.
HNS represents a radical paradigm change in the treatment of sleep apnea, introducing an implantable device to stimulate the tongue muscles with the aim of reducing airway obstruction while sleeping.
Mechanism of Effectiveness: The device utilizes mild electrical pulses sent to the hypoglossal nerve branch to stimulate the genioglossus muscle to prevent tongue-based obstruction. This method exerts a targeted approach to tongue base collapse, which is a common etiology in the treatment of OSA that is otherwise unresponsive to treatment.
Clinical Effectiveness: The Inspire device reduced the AHI by 20.14 events/hour in the short term and 15.91 events/hour in the long term. The surgical success rates of Inspire devices were 72.4% at the 12-month follow-up and remained at 75% at the 60-month follow-up.
Patient Criteria: Candidates should have:
Long-Term Outcomes: Studies show there is a 68% reduction in AHI with sustained longer-term quality of life and daytime sleepiness improvements. The treatment also has a high level of patient satisfaction due to not having to wear a mask or external device.
We asked Dr. Suzanne Gorovoy, Sleep Expert, Clinical Psychologist, and Behavioral Sleep Medicine Specialist, about the benefits of HNS. She states: "Hypoglossal nerve stimulation offers freedom from masks and still maintains very good treatment outcomes." This represents a significant change in quality of life for patients who cannot tolerate the mask and CPAP, encompassing both the physical and psychological limitations associated with adherence to treatment.
Maxillomandibular advancement surgery includes the forward repositioning of both the upper and lower jaw in an effort to physically expand the airway space. MMA surgery achieves the highest success rate among current surgical alternatives.
Surgical Technique: The MMA is performed by forward-fixing the maxilla and the mandible approximately 10mm via Le Fort I maxillary and sagittal split mandibular osteotomies. This extensive skeletal realignment increases the entire upper airway, from the nose to the larynx.
High Rates of Success: Based on meta-analysis data, 98.8% of patients with MMA had a favorable response to treatment and had an average AHI reduction of 47.8 events/hour, with an overall success rate of 80.1%. An independent analysis found that 24% of patients achieved a complete cure (AHI ≤5) and 33% achieved near-normal breathing (AHI ≤10).
Patient Selection: Patients with significant cardiovascular disease had 0.140 times lower odds of a favorable response, while an increased central apnea index and large superior posterior airway space were associated with less likelihood of treatment success. The best candidates for MMA tend to have primarily obstructive (non-central) apnea types and limited comorbidities.
Long-Term Effectiveness: MMA results in large and sustained decreases in AHI, diastolic blood pressure, and subjective sleepiness with little long-term adverse events. MMA outcomes tend to be more stable over time compared to all soft tissue procedures due to the skeletal nature of the surgical procedure.
Many patients benefit from combination surgical approaches that treat multiple sites of obstruction at once. Common combinations include:
New modified UPPP techniques, including expansion sphincter pharyngoplasty and barbed repositioning pharyngoplasty, demonstrate better outcomes than regular UPPP. New procedures allow the surgeon to preserve more functional tissue while achieving the same or better outcomes.
Targeted Hypoglossal Nerve Stimulation: Proximal targeted hypoglossal nerve stimulation has been proven safe and effective and produces clinically significant improvements in OSA patients across a wide spectrum of patients. This may expand treatment eligibility beyond the current limitations of HNS.
Computer-Assisted Surgery: CAD/CAM-assisted MMA methods demonstrate equivalent outcomes as earlier surgical approaches, but they offer more simplicity and lower duration of surgery. Digital planning increases the accuracy and predictability associated with complex surgical procedures of the skeleton.
Healthcare professionals should educate patients about surgical risks to allow safe and informed decisions regarding treatment options. Each surgical procedure has a specific risk profile to consider, with risks and complications weighed against the expected benefits of surgery.
UPPP:
HNS:
MMA:
We asked Dr. Areti Vassilopoulos, Sleep Expert, Pediatric Health Psychologist, and Assistant Professor of Child Psychology, about risk counseling. According to Dr. Vassilopoulos: "Comprehensive counseling that includes the risks of surgery, as well as the benefits, sets patients up for reasonable expectations during a very stressful decision-making process." More realistically defined expectations in the preoperative phase can lead to improved postoperative satisfaction, especially given that most surgery for sleep apnea is elective.
Current literature reports about the success rate of surgical management of sleep apnea shows:
All sleep surgery for obstructive sleep apnea must have thoughtful patient evaluation and selection. Multiple specialists and diagnostic procedures are used to identify the best candidate for each procedure.
Polysomnography Assessment: In-depth analysis of a sleep study provides information about:
Drug-Induced Sleep Endoscopy (DISE): DISE is conducted under anesthesia to evaluate patterns of airway collapse and predict candidate success for surgery. This important assessment learns which anatomical sites are contributing to obstruction and assists in choosing which procedure is suitable for the candidate.
Cephalometric Assessment: Lateral X-rays of the skull can establish skeletal relationships and soft tissue proportions that affect airway dimensions. Examples of important measurements include:
CT Imaging: 3D imaging to assess regional anatomy of the airway and provide exact measurements of:
Understanding what to expect in recovery gives patients an opportunity to mentally prepare for the surgical experience and provide the best opportunities for their recovery with short- and long-term postoperative care.
UPPP Recovery Timeline:
HNS Recovery Timeline:
MMA Recovery Timeline:
Weight Management: Healthy weight maintenance has a dramatic effect on surgical outcomes across all surgeries. Increased BMI consistently predicts lessened surgical outcomes and should be addressed before and after surgery.
Sleep Hygiene Maintenance: Continued attention to sleep hygiene principles will further support improved surgical outcomes by continuing to optimize overall sleep quality and architecture.
Current research is focused on improving patient selection criteria and developing less invasive techniques. There are several promising areas that could eventually transform sleep apnea surgery:
Artificial Intelligence in Patient Selection: The use of machine learning algorithms that assess multiple variables (anatomical, physiological, and demographic) may soon result in better prediction of surgical outcomes compared to current methods. With this, we could improve success rates and minimize unsuccessful procedures.
Biomarkers for Surgical Response: The study of genetic and inflammatory markers that predict surgical response are critical and potentially impactful for patient selection. Early research has suggested that certain genetic variants can have an effect on the collapsibility of the upper airway and are associated with an individual person's response to intervention.
Minimally Invasive Techniques: The advancement of radiofrequency, laser, and robotic techniques aims at having the surgical effect of improved airway patency with less morbidity. These minimally invasive techniques may also afford individual patients more treatment options than those patients who are not able to accept definitive surgical treatment.
Combined Device Therapies: The combination of therapies, such as using a hypoglossal nerve stimulator with an oral appliance or positional therapy, is now being studied to determine if patient outcomes will improve in a more difficult patient population with sleep apnea while using only one treatment modality.
Understanding the financial aspect of treatment will help patients plan for treatment options and their associated costs.
Most insurances, including Medicare, will cover sleep apnea surgery when the procedural surgery can demonstrate meeting medical necessity when proper documentation is present. The documented evidence needed to be considered medically necessary surgery includes:
The insurance-covered programs available through Sleep Reset also offer alternative approaches for patients who want a non-surgical approach to treatment or for patients who are preparing for surgical intervention.
Patients should consider all options available to them when deciding whether to pursue surgery for sleep apnea, as well as specific patient factors.
Optimal Patient Factors:
Consider Non-Surgical Strategies When:
Behavioral Sleep Medicine Interventions: In a CBT-I program, such as Sleep Reset, the underlying sleep behavior is addressed, and therefore it may also reduce the severity of obstructive sleep apnea through better sleep efficiency and less sleep fragmentation. Behavioral sleep medicine interventions are not a cure for moderate or severe obstructive sleep apnea but can be used as an adjunct to surgical treatment or for milder cases if proper sleep behavior modification is successful.
Surgery is a powerful treatment option for sleep apnea for those patients who have an inability to use or benefit from CPAP therapy. Surgery success rates range from 50%-95%, depending on the surgical procedure and proper patient selection. Surgical options can offer a therapeutic alternative to the millions of people who suffer from untreated sleep-disordered breathing.
The key to a surgical procedure's outcome or success is in selecting an appropriate surgical patient, setting realistic expectations for the procedure, and conducting a highly collaborative, comprehensive preoperative evaluation. As surgical techniques continue to evolve and technology improves, the treatment spectrum for sleep apnea will likely continue to broaden with more tailored and personal options for treatment.
For patients who consider surgery, a consultative process with a sleep medicine specialist and a multidisciplinary team (e.g., ENT surgeon, oral and maxillofacial surgeon, or behavioral sleep medicine expert) will result in the most optimal treatment planning. Surgery represents a considerable decision but can be life-changing for the appropriate patient, with potentially sustainable freedom from needing a device while improving overall health and sleep quality.
Overall, the objective remains, whether surgical or nonsurgical, to achieve restorative sleep that will sustain long, healthy living and quality of life. Ultimately, knowing your sleep patterns and needs gives you the best opportunity to make informed treatment decisions pertaining to your circumstances and values.
Dr. Shiyan Yeo
Dr. Shiyan Yeo is a medical doctor with over a decade of experience treating patients with chronic conditions. She graduated from the University of Manchester with a Bachelor of Medicine and Surgery (MBChB UK) and spent several years working at the National Health Service (NHS) in the United Kingdom, several Singapore government hospitals, and private functional medicine hospitals. Dr. Yeo specializes in root cause analysis, addressing hormonal, gut health, and lifestyle factors to treat chronic conditions. Drawing from her own experiences, she is dedicated to empowering others to optimize their health. She loves traveling, exploring nature, and spending quality time with family and friends.
