AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Snoring, excessive daytime somnolence, restless sleep, and apnea are manifestations of sleep-disordered breathing, which has plagued society for centuries. Recent understanding of the pathophysiology related to these problems has led to some successes in both nonsurgical and surgical interventions.

Numerous sleep disorders are organized in the International Classification of Sleep Disorders by the American Sleep Disorders Association. The primary disorders that may warrant surgical intervention include snoring and obstructive sleep apnea (OSA). The otolaryngologist's approach to management and treatment of these conditions is discussed below.

Problem

Snoring is an undesirable sound that originates from the soft tissues of the upper airway during sleep. It is usually a source of contention for patients and their bed or dwelling partners, and it may be a harbinger of something more serious, such as OSA.

OSA is a sleep disorder in which airflow is repeatedly reduced or ceased. The disorder may vary in severity and is often associated with other physiologic problems. These problems include altered mood and behavior (depression, lethargy, cognitive and memory impairment), morning headaches, decreased libido, systemic and pulmonary hypertension, congestive heart failure, and sleep-related arrhythmias, among others. 

Apnea is obstructive only when polysomnography reveals a continued inspiratory effort evidenced by abdominal and thoracic muscle contraction. In central apnea, absence of airflow accompanies a lack of inspiratory effort, and this condition is not amenable to surgical correction. At times, apnea may be mixed, occurring with both obstructive and central apnea symptoms. Patients with this condition present a therapeutic challenge to the surgeon.

Frequency

The exact prevalence of OSA is unknown, but most experts agree it is frequently undiagnosed. A large study of 602 patients showed that 28% of women and 44% of men aged 30-60 years reported habitual snoring. Polysomnography demonstrated that 9% of women and 24% of men had a respiratory disturbance index (RDI) of 5 or higher, suggesting some degree of sleep apnea.

Age: OSA can occur at any age, but it is most commonly diagnosed in patients aged 45-65 years.

Sex: In adults, the male-to-female ratio is approximately 2:1.

Etiology

Snoring is a result of incomplete pharyngeal obstruction. Turbulent airflow and subsequent progressive vibratory trauma to the soft tissues of the upper airway are important factors that contribute to the condition. Anatomic obstruction leads to increased negative inspiratory pressure, which propagates further airway collapse, turbulence, and noise.

The imbalance between the forces that act to maintain airway patency (the force of the pharyngeal muscles) and the negative inspiratory forces generated by the diaphragm is thought to be the primary etiology of anatomic obstruction in OSA. In OSA, the tongue contacts the soft palate and posterior pharyngeal wall in the presence of lateral collapse of the pharynx, generating occlusion.

Significant factors that contribute to this condition include obesity, redundant tissue in the neck, retrognathia, and craniofacial anomalies. In addition, anatomic abnormalities of the nasal airway (eg, septal deviation, inferior turbinate hypertrophy, nasal-valve narrowing, adenoid hypertrophy) may play a role. Alcohol and other sedatives may increase the severity of OSA. Data from a recent meta-analysis by Rada also suggested a causal relationship between OSA and head and neck cancer (which may first manifest as OSA).

Pathophysiology

Three factors involved in the development of OSA include decreased dilating forces of the pharyngeal dilators, upper-airway anatomic abnormalities, and the negative inspiratory pressure the diaphragm generates. The site of obstruction is primarily in the pharynx; however, many anatomic sites clearly contribute. The muscles of the upper airway, including the sternohyoid, genioglossus, and tensor palatini, work together to dilate or stiffen the extrathoracic airway and to maintain its airway caliber.

Collapse may begin when the base of the tongue abuts the posterior pharyngeal wall and soft palate. This may progress to the lower pharynx. The exact cause of upper airway collapse in humans has not been completely elucidated. An animal study, however, revealed nearly abolished genioglossal activity during rapid eye movement (REM) sleep, even in the presence of elevated inspired carbon dioxide levels (Parisi, 1988).  Data from recent studies have also suggested that nasal obstruction plays a prominent role in OSA.

Extended or excessive tissue of the soft palate, a large tongue base, a large uvula, large tonsils, and redundant pharyngeal mucosa are correlated with a narrowed upper airway. With airway narrowing, increased inspiratory pressure is needed to maintain adequate ventilation. A virtual vacuum on inspiration promotes further collapse of the soft tissue, which often has poor tone due to repeated vibratory trauma. Of importance is the finding that increased pulmonary resistance also requires increased negative inspiratory pressures.

Nocturnal oxygen desaturation and hypercapnia associated with OSA increases arterial blood pressure in both the systemic and pulmonary circulations. Over time, hypertension can lead to cardiac hypertrophy and decompensation. Cor pulmonale is a classic clinical manifestation of long-standing OSA. The Sleep Heart Study and Wisconsin Sleep Cohort Studies provide the most compelling evidence that patients with sleep-disordered breathing have a significantly greater risk of developing hypertension and requiring antihypertensive medications (Nieto, 2000; Peppard, 2000).

Arrhythmias can also occur as a result of cardiopulmonary strain secondary to hypoxia. In rare cases, this may lead to nocturnal death. Diminished oxygen saturation also stimulates erythropoiesis and clinical polycythemia. Additionally, OSA has been implicated as a risk factor for first stroke, recurrent stroke, and poststroke mortality (Dyken, 1996).

Clinical

History

A useful source for obtaining a history for a patient who snores is the patient's bed partner. Typical symptoms include snoring, apneic episodes (witnessed by a bed partner), excessive daytime somnolence, and difficulty with memory and cognition. Other indicators might include enuresis (bed wetting) or a history of maxillofacial trauma.

Patients who are referred for a surgical evaluation often report failed treatment with continuous positive airway pressure (CPAP). Treatment with CPAP usually fails because the patient cannot tolerate or dislikes the cumbersome CPAP facial appliance. Although most studies report a 95% success rate, actual compliance for adequate use, over several years, is about 6%. Adequate use is defined as at least 7 hours for more than 70% of days.

Physical examination

Many patients do not voluntarily report snoring to their physicians because of the social embarrassment often associated with this problem. The author has found the simple question, "Has anybody mentioned to you that you snore from time to time?" to be extremely helpful and nonconfrontational.

The author has found several structural predictors of OSA  to be useful. Most patients with sleep apnea are overweight and have short, thick necks. Increasing neck circumference is linearly related to the probability of OSA and may be more specific than body mass index (BMI) in the clinical diagnosis of OSA. Maxillary and mandibular deficiency is an important finding and can be initially examined by evaluating the dental occlusion. The absence of mandibular teeth may also lead to mandibular atrophy. Examination of the oropharynx often reveals an elongated uvula, a small oropharyngeal opening, a large tongue, and prominent oropharyngeal folds. The uvula may telescope upon itself when the patient says "ah," indicating an increased possibility that OSA is present.

A recent study demonstrated a 70% positive predictive value of tongue scalloping and OSA. Scalloping of the tongue was defined as the multiple lateral glossal indentions that result from molar compression (Weiss, 2005). Occasionally, large tonsils are seen in adults, but this is found more often in pediatric patients. Direct fiberoptic examination or indirect mirror examination may reveal a mass or tumor in the upper airway or possible deviation of the nasal septum. The author always performs a complete upper airway examination  to exclude unusual causes for upper airway obstruction, such as a neoplasm.

Completely examine the nose, nasopharynx, oral cavity, oropharynx, hypopharynx, larynx, and neck. In the Müeller maneuver, the patient inhales with their nasal passages occluded and their lips closed while the airway is examined with a flexible fiberoptic laryngoscope. Ascertaining the level of greatest obstruction is often helpful but can be difficult, particularly in the pharynx. The findings of a Müeller maneuver, for example, dramatically differ from the sleep-breathing situation.

In the surgical candidate, video sleep nasoendoscopy (VSE) has been advocated to assess the sites of obstruction. Close attention should be paid to the levels of the soft palate, lateral pharyngeal wall, tonsils, tongue base, epiglottis, and hypopharynx (the piriform fossae that collapses in around the larynx; Abdullah, 2003). This technique has been criticized in the past for inducing false-positive results (ie, causing snoring and obstruction in a patient who normally does not have this problem). A recent study showed that sleep nasendoscopy can be used without falsely producing snoring and obstruction in patients if propofol and a pump with a microprocessor that allows a controlled, determined intravenous infusion rate are used (Berry, 2005).

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical management of snoring and obstructive sleep apnea (OSA) is indicated when a surgically correctable abnormality is believed to be the source of the problem and the patient has tried continuous positive airway pressure (CPAP) without success. In addition, many patients opt for surgical treatment after noninvasive forms of treatment have proven ineffective or difficult to tolerate.

Studies have demonstrated that an apnea index of 20 or more, even in asymptomatic patients, is associated with an increased mortality rate. The author spends a significant amount of time educating patients about treatment options and the risks of untreated OSA (eg, hypertension, stroke, cardiovascular disease).

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical alteration of the upper airway usually involves 1 or more structures, including the nasal septum, inferior nasal turbinates, adenoids, tonsils, anterior and posterior tonsillar pillars, uvula, soft palate, or the base of the tongue. Craniofacial abnormalities, whether acquired or congenital, may also be amendable to surgical correction. In unusual cases, obstruction may occur at the level of the larynx (eg, tumor, laryngomalacia).

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Palatal surgery is contraindicated in patients with velopharyngeal insufficiency or a submucous cleft palate. Medical conditions that preclude the use of a general anesthetic are a relative contraindication to surgery.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Laboratory studies are generally unnecessary in the workup of a patient with sleep-disordered breathing. A CBC count may be useful if anemia is suspected. Generally, a low-grade polycythemia is present due to chronic or recurrent bouts of hypoxia. A test for growth hormone level or thyroid stimulating hormone level is necessary only if the presence of acromegaly or hypothyroidism is clinically supported.

Imaging Studies

• Cephalometric radiography (plain radiography of the airways): The value of radiography in routine presurgical workup is highly debated. The study is most useful in assessing craniofacial skeletal abnormalities. Lateral airway images can be helpful in diagnosing adenoid hypertrophy in young pediatric patients.
• CT scanning or MRI: These procedures are rarely performed in the workup for obstructive sleep apnea (OSA) because they do little to guide therapeutic intervention, they are expensive, and they expose patients to unnecessary radiation.
• Chest radiography: Radiographs may depict right ventricular hypertrophy due to persistent pulmonary vasoconstriction (cor pulmonale).

Other Tests

• Electrocardiography may be useful in evaluating for cardiac dysrhythmias.

Diagnostic Procedures

• Polysomnography is the criterion standard for diagnosing sleep apnea.
• • Diagnostic information gathered in a sleep laboratory includes the stages of sleep and the number and types of apneic events.
  • Continuous oxygen saturation monitoring and continuous ECG tracings are also performed.
  • A complete polysomnographic study includes electroencephalography for sleep staging, bilateral electro-oculography, submental electromyography, nasal and oral air-flow assessments, respiratory muscle movement or effort assessment, oxygen saturation testing, electrocardiography, anterior tibialis electromyography, and sleep-position assessment.
  • The study should be completed during the patient's normal sleep time and include a minimum of 2-4 hours of sleep.
• Several parameters may be measured.
• • The apnea index is defined as the number of apnea episodes per hour. Apnea is defined as the absence of airflow at the nose and mouth that lasts for at least 10 seconds during sleep.
  • The respiratory disturbance index (RDI), or apnea-hypopnea index (AHI), is defined as the combined number of apneic and hypopneic events per hour of sleep.
  • Hypopnea means underbreathing and is relatively more difficult to define. Most agree that airflow must be decreased by about 50% and associated with about a 4% decrease in blood-oxygen saturation to be considered hypopnea. Some add an arousal from sleep to this definition. The authors define hypopnea as a reduction in airflow of 30% or greater for 10 seconds or longer associated with an oxyhemoglobin desaturation of 4% or more.
  • The association of sleep-disordered breathing with cardiovascular disease has been reported in 5250 patients (Shahar, 2001).
  • The RDI, lowest oxygen saturation(s) level for the night, length of time with oxygen saturation less than 90%, and ECG findings are the most important factors. Surgeons use these parameters to determine treatment options based on the severity of the apnea.
  • The severity of OSA is arbitrarily defined and differs widely among centers. Recent recommendations for cutoff levels based on RDIs are as follows:
  • • Mild OSA is defined as 5-15 episodes per hour.
    • Moderate OSA is defined as 15-30 episodes per hour.
    • Severe OSA is defined as more than 30 episodes per hour.
• Home polysomnography: This portable form of sleep study has gained limited acceptance because trained or qualified personnel often do not perform the test. A recent study compared a widely available home unit (SNAP) with a 12-lead sleep-laboratory polysomnography. Although not widely accepted, SNAP is considered by the authors to be a suitable alternative to traditional polysomnography (Michaelson, 2006).
• Nocturnal oximetry: If the patient's oxygen saturation is below 90% during less than 1% of his or her sleep time, apnea is not clinically significant.
• Acoustic recording: An audio recording is analyzed for apneic episodes, primarily to help confirm the diagnosis in children. However, this test has a poor predictive value if the results are negative. Nocturnal polysomnography remains the diagnostic criterion standard in children and adults.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

Various medications have improved, with limited success, the activity of the upper airway muscles during sleep.

The mainstay of nonsurgical treatment for snoring and obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP), which became readily available in 1981. The positive airway pressure acts as a pneumatic stent to resist airway collapse. CPAP is administered through a nasal mask, nasal prongs, or a mask that covers both the nose and mouth. This treatment requires that the patient comply with wearing a mask, which some consider uncomfortable, at night. Patients who frequently travel may consider carrying a machine as impractical, regardless of the unit's compactness.

Oral appliances or mandible advancement devices alter the position of the tongue base and mandible, respectively, in an effort to relieve obstruction. A survey of 110 patients who were treated with an oral appliance in a hospital-based dental practice revealed a success rate of more than 50%  at 18 months (Dort, 2004). In small children, a nasal trumpet often prevents airway collapse and OSA. These measures are considered temporary.

Behavioral: The mainstay of behavioral therapy is weight loss and repositioning of the body during sleep to reduce snoring and apneic episodes. Some cases of OSA resolve with weight loss alone; however, long-term success is debated because many patients regain the weight. In addition, weight loss has not been proven to significantly improve the RDI in patients with moderate-to-severe sleep apnea.

In a recent study, Lankford et al evaluated 15 patients who had lost an average of 44.5 kg after undergoing Roux-en-Y gastric bypass. The same patients were able to reduce the pressure used on their CPAP machines by 18% (11 cm before surgery to 9 cm after surgery). The clinical significance of this change is questionable.

Other: A brief Internet search reveals countless claims about products that reduce or eliminate snoring. Such merchandise includes antisnoring pillows, throat sprays, chin straps, and Breathe Right strips, among others.

Surgical therapy

When surgical therapy is indicated, conservative procedures are attempted first. These procedures include uvulectomy, nasal reconstruction, adenotonsillectomy, and palatal implants. More aggressive operations include uvulopalatopharyngoplasty (UPPP or UP3) and genioglossal advancement with hyoid myotomy. Second-line treatments for OSA are more complex and include maxillary-mandibular advancement, bimaxillary advancement, palatal advancement and tongue-base surgery (midline glossectomy), and tracheostomy.

Uvulectomy 

A patient with a large uvula who snores and has few or no symptoms of apnea may benefit from uvulectomy. The patient can be given local anesthesia, and uvulectomy can be performed as an office procedure by using cautery or a carbon dioxide laser. In 1993, laser-assisted uvulopalatoplasty was first described as a procedure for individuals with mild OSA who snore. The procedure consists of incising the inferior rim of the soft palate and uvula. The tonsils are not removed.

Pillar system

The Pillar procedure, or palatal implants, is a relatively new and minimally invasive modality used to treat people with habitual snoring and those with mild-to-moderate OSA. The Pillar procedure addresses the soft palate, which is one of the anatomic components of sleep apnea and snoring.

During the Pillar procedure, 3 tiny woven inserts are placed in the soft palate to help reduce the vibration that causes snoring and the ability of the soft palate to obstruct the airway. Once in place, the inserts add structural support to the soft palate. Over time, the body's natural tissue response to the inserts increases the structural integrity of the soft palate. This procedure can be performed in the office or in the operating room as an adjunctive procedure.

A study performed in Norway indicated that the procedure is relatively successful (70%) in terms of bed-partner satisfaction (Nordgard, 2006). The cure rate depends on the severity of the preoperative sleep apnea. In most cases, the author encourages patients to undergo an overnight sleep study to assess the severity of the sleep-disordered breathing. On October 31, 2006, Medicare recognized this procedure and will reimburse the hospital for the implant devices. To date, most private insurance companies do not pay for the device and no carrier, to the author's knowledge, pays the surgeon.

Nasal reconstruction

Relief of nasal obstruction alone rarely cures OSA; however, patient tolerance and response to nasal CPAP are often improved. Septoplasty, septorhinoplasty, and turbinate reduction may be indicated in patients who have a predisposed anatomy. Turbinates can be reduced in a number of different ways, including traditional total or partial turbinectomies, submucous resection, cryotherapy, laser vaporization, bipolar radiofrequency coblation, and radiofrequency ablation. The author, 18 months ago, began to perform the lateral crural-J flap and found this procedure to be useful in patients with external nasal valve collapse who have had trouble tolerating CPAP with the nasal pillows mask.

Adenotonsillectomy

Adenotonsillectomy is often performed in the pediatric population to correct loud snoring and restless sleep. OSA is the primary indication for tonsillectomy in the pediatric population. The tonsils and adenoids can be removed or reduced in a number of ways. The surgeon's preference, cost, and postoperative pain and complications dictate which methods are used in each institution, which are subject to change over time. The methods include use of standard cautery, snare, bipolar cautery, harmonic scalpel, coblation, temperature-controlled radiofrequency, or microdebrider-powered shavers. In children, palatal surgery is usually necessary only in cases of extreme obesity.

Palatal surgery

UPPP is the most common procedure for the treatment of OSA syndrome. This procedure, introduced by Fujita in 1981, consists of tonsillectomy, reorientation of the anterior and posterior tonsillar pillars, and excision of the uvula and posterior rim of the soft palate. For patients without tonsils and enlarged tongue bases, Friedman advocated a Z-palatoplasty.

Transpalatal advancement pharyngoplasty has also been described and includes the removal of a portion of the posterior hard palate and anterior suspension of the soft palate. This procedure has evolved because of the unpredictable success of UPPP but is not widely performed in the United States.

Genioglossal advancement

Genioglossal advancement involves performing a mandibular osteotomy with anterior repositioning of the genioglossus-attached segment of the mandible. This procedure results in anterior displacement of the tongue.

Thyrohyoid suspension

Friedman designed thyrohyoid suspension for patients with moderate-to-severe OSA without enlarged palatine tonsils or patients with a short (<40-mm) hyomental distance. This procedure involves making a horizontal incision in the midline of the neck and advancing the hyoid bone anteriorly and inferiorly to the thyroid cartilage. In essence, this procedure draws the base of the tongue forward, making it less likely to fall back against the posterior pharyngeal wall during sleep. In addition, the hyoid bone may be repositioned anteriorly with transection of the infrahyoid muscles and suspension to the mandible.

Maxillary-mandibular advancement

Maxillary-mandibular advancement is performed in an attempt to widen the airway while maintaining the existing occlusion or, optimally, to obtain class I occlusion. Outer-table cranial bone is obtained initially through a coronal incision. Arch bars are placed, and maxillary osteotomies are performed. The maxilla is advanced 8-12 mm. Mandibular osteometries are also performed, and the mandible is advanced to obtain optimal occlusion. Bone grafts are used at the osteotomy sites as needed. Intermaxillary fixation is necessary postoperatively. A wide variety of maxillomandibular advancement techniques have been described, all with the goal of advancing skeletal support for the tongue and pharynx.

Tongue-base surgery

Lingual tonsillectomy, lingualplasty, and laser midline glossectomy are moderately successful procedures designed to reduce the mass of the tongue base. Proper postoperative airway support requires a temporary tracheotomy.

Radiofrequency ablation

Temperature-controlled radiofrequency tissue ablation (TCRFTA) is performed by  submucosally delivering low-power electrical energy with a needle electrode. This procedure has been proposed to improve airway patency with less morbidity than that of traditional surgical approaches for OSA. This technology has been used in the tongue base and in the soft palate, sometimes both in the same setting. This procedure can be performed in the clinic with local anesthesia. Multiple treatments may accomplish the desired result.

Tracheotomy

Permanent tracheotomy cures OSA and is indicated most often in patients with severe apnea that is associated with life-threatening cardiac arrhythmias. Other less frequent indications may include morbid obesity, obstruction with severe hypoxia, and disabling daytime somnolence. This is not commonly used today.

Postoperative details

Elevating the patient's bed in the recovery room and having a bilevel positive airway pressure (Bi-PAP) or CPAP device readily available is useful.

Traditionally, patients who undergo UPPP have been kept at least overnight to allow airway observation and to ensure adequate oral intake. Most serious complications seem to occur within the first 2-3 hours after surgery, and many patients (who have not undergone multilevel airway surgery) can be safely discharged home with detailed instructions (Spiegel, 2005). Patients who are discharged the day of surgery are counseled by the author to sleep in a recliner for the first 2 nights and to try to use their CPAP device if possible. Ensuring that the patient lives relatively close to the hospital and has reliable transportation is crucial.

Follow-up

After surgical procedures, polysomnography is necessary to assess the outcome. Six months is a generally accepted interval.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Postobstructive pulmonary edema occasionally occurs after relief of clinically significant airway obstruction. This condition manifests as airway edema and respiratory distress, and it results from the dramatic alteration in pulmonary physiology that follows obstruction removal.

Complications from septoplasty include nasal bleeding, septal hematoma, injury to the skull base that results in altered sense of smell or cerebrospinal leak, and septal perforation. Nasal crusting and bleeding can occur after turbinoplasty, regardless of the method used to reduce their size. Rhinoplasty may leave the patient with an unappealing cosmetic result that may require further surgery.

The palatal Pillar system has been used for only the past few years. To date, complications include superficial mucosal ulcerations and dislodgement of the pillar implants. The complications rate seems to be about 3%, based on the studies currently available.

Minor bleeding is the only common complication of uvulopalatoplasty; uvulopalatopharyngoplasty (UPPP) may provoke more significant bleeding when the tonsils are removed. Airway obstruction, velopharyngeal insufficiency, and nasopharyngeal stenosis are less common complications of UPPP. Most advocate inpatient care in a closely monitored unit. The most common (10-12%) complication of transpalatal advancement pharyngoplasty is an oronasal fistula,  which seems to be temporary in most cases.

Tongue-base surgery is sometimes associated with bleeding, dysphagia, odynophagia, and airway edema. Superficial ulcer formation, hypoglossal nerve injury, and abscess are less common complications. Taste may also be altered after tongue-base surgery and, in rare cases, standard tonsillectomy.

Radiofrequency ablation of the tongue base and soft palate is associated with rare, minor complications. These include mild pain, swelling, and mucosal ulceration that generally resolves unaided within 1-2 months.

Genioglossal advancement with hyoid suspension may be complicated by bleeding or infection in the floor of the mouth, Warthin duct injury, dental trauma, neck hematoma, pharyngocutaneous fistula, and wound infection.

Maxillary-mandibular advancement procedures may result in injury to the lingular neurovascular bundle. Most sensory impairments resolve over time. Cosmesis is generally not a problem.

The complications of tracheotomy include bleeding, pneumothorax, subcutaneous emphysema, and formation of peristomal scar tissue. Early tube dislodgment can occur and may result in hypoxia and death if not promptly replaced.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Most investigators define successful treatment as a decrease of 50% in the respiratory disturbance index (RDI) and a decrease in this number to less than 20 on postpolysomnography. Other, less objective measures include an improvement in the patient’s energy level and ability to concentrate.

The 59% surgical success rate of multilevel temperature-controlled radiofrequency tissue ablation (TCRFTA) in the study by Steward was comparable with published success rates of 50% with uvulopalatopharyngoplasty (UPPP) and tongue-base TCRFTA and published success rates of 42-59% with UPPP and midline glossectomy. The published success rate with UPPP and genioglossus advancement is 35-77%, with or without hyoid myotomy and suspension. The published success rates of 90% or more with combined UPPP, genioglossus advancement, and maxillary-mandibular advancement are most impressive.

Patients at less than 125% of their ideal body weight are most likely to have short-term and long-term benefits from surgical treatment of snoring and obstructive sleep apnea (OSA). Other important variables include severity of disease, age at onset of symptoms, and comorbidities.

Patients with mild obstructive disease are more likely to respond to surgical treatment than those with more severe disease.

Outcome data from numerous studies have demonstrated significant short-term benefits from the aforementioned surgical procedures in appropriately selected patients. Additional efforts also affect the long-term results and prognosis for patients.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical treatment of obstructive sleep apnea (OSA) is an option in affected patients who cannot tolerate continuous positive airway pressure (CPAP). As noted above, many procedures are available, but uvulopalatopharyngoplasty (UPPP) is the most frequently performed procedure. Further investigation of the pathophysiology of OSA and the long-term efficacy of current surgical therapy is indicated and ongoing.

A growing number of reports in the literature demonstrate an ongoing commitment among scientists and physicians to improve our understanding of sleep-disordered breathing. In addition, in the United States alone, the Stanford Sleep Disorders clinic conducts a fellowship to train physicians in the subspecialty of sleep disorders. The American Academy of Sleep Medicine specifically promotes the advancement of sleep medicine and better health among those who have sleep-disordered breathing.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Uvulopalatopharyngoplasty.
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Media file 2:  Hyoid suspension for obstructive sleep apnea. The infrahyoid muscles are detached from the body of the hyoid bone using electrocautery. Reprinted from Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 13(2). Krespi YP and Kacker A, Hyoid suspension for obstructive sleep apnea, p144-149, copyright 2002 with permission from Elsevier.
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Media file 3:  Hyoid suspension for obstructive sleep apnea. The hyoid is divided in the midline, and the loop suture is passed around the hyoid. The loop suture is suspended to the mandible, thereby suspending the tongue base anterosuperiorly. This enhances the posterior air space. A variation of this procedure is the hyoid advancement, whereby the hyoid is advanced, with several sutures (ie, 2-0 Ethibond) anteriorly and inferiorly over the thyroid lamina. Reprinted from Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 13(2). Krespi YP and Kacker A, Hyoid suspension for obstructive sleep apnea, p144-149, copyright 2002 with permission from Elsevier.
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Media file 4:  Maxillary-mandibular advancement in obstructive sleep apnea. Final appearance of the advancement with rigid fixation. Reprinted from Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 13(2). Hester JE, Powell NB, Riley RW, and Li KK, Maxillary-mandibular advancement in obstructive sleep apnea, p135-137, copyright 2002 with permission from Elsevier.
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Media file 5:  Bipolar radiofrequency cold ablation turbinate reduction for obstructive inferior turbinate hypertrophy. Depiction of linear passage of the coblation wand. Reprinted from Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 13(2). Bhattacharyya N and Kepnes LJ, Bipolar radiofrequency cold ablation turbinate reduction for obstructive inferior turbinate hypertrophy, p170-174, copyright 2002 with permission from Elsevier.
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Media file 6:  Bipolar radiofrequency cold ablation turbinate reduction for obstructive inferior turbinate hypertrophy. Anterior rhinoscopic view of the coblation wand as it enters the anterior head of the right inferior turbinate. Reprinted from Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 13(2). Bhattacharyya N and Kepnes LJ, Bipolar radiofrequency cold ablation turbinate reduction for obstructive inferior turbinate hypertrophy, p170-174, copyright 2002 with permission from Elsevier.
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

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Article Last Updated: Apr 27, 2007