Obstructive Sleep Apnea

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Surgery

Minimally Invasive Treatment
The Pillar® procedure, also called palatal restoration, is a relatively new, minimally invasive procedure approved by the Food and Drug Administration (FDA) to treat mild to moderate OSA caused by the soft palate.

This procedure is performed in a physician's office, using local anesthesia. It involves implanting 3 small woven inserts into the soft palate to help support and improve the structure of the palate, and reduce airway obstruction.

Following the procedure, most patients are able to resume normal activities and diet the same day. Over-the-counter pain medications may be used to relieve minor discomfort.

The Pillar® procedure has been shown to permanently reduce OSA in approximately 80% of cases. Complications are rare and include partial extrusion, which involves seeing or feeling the tip of the insert through the surface of the soft palate. The inserts used can be removed and/or replaced easily by a physician.

Surgical Treatment
Several surgical procedures may be used for the treatment of OSA. These include: uvulopalatopharngeoplasty (UP3), geniotubercle advancement, hyoid myotomy and resuspension, midface advancement, and tracheostomy.

In children, where the cause of OSA is usually tonsil and adenoid enlargement, surgical removal of the enlarged tonsils and adenoids is the treatment of choice for OSA.

Overall, uvulopalatopharneoplasty (UP3) is the most common surgical procedure for treating OSA. This involves removing the uvula and some of the surrounding soft palate. The idea behind UP3 is to eliminate the area of obstruction or to widen the airway so it does not occlude completely. UP3 eliminates OSA approximately 50% of the time. The complications of UP3 include transient nasal reflux, nasal speech, minor loss of taste, and tongue numbness.

There is significant discomfort after the surgery for about 2 weeks. More significant, and infrequent, complications include permanent nasal reflux, changes in the person's voice and palatal stenosis, which can make OSA worse. UP3 is very effective for eliminating snoring. Because snoring is generally the most easily measured sign of OSA, patients undergoing UP3 are advised to undergo another sleep study 6 months after surgery to verify its effectiveness.

Geniotubercle advancement and hyoid myotomy and resuspension are sometimes done in conjunction with a UP3 or if a UP3 has proven ineffective. The geniotubercle advancement is done by making a small cut into the midline of the mandible (jawbone) and repositioning a small piece of bone. This bone, the geniotubercle, attaches to the tongue muscles. As the geniotubercle is pulled forward, the tongue is also pulled forward, potentially relieving any airway obstruction caused by the base of the tongue.

A hyoid myotomy is often performed in conjunction with the geniotubercle advancement. The hyoid is a bone in the anterior upper neck. This surgery is felt to advance the base of the tongue as well. Complications from hyoid myotomy are rare but include dental nerve anesthesia and mandibular fractures extending into the root system of the teeth. A combined success rate of approximately 70% has been reported where UP3 has been combined with geniotubercle advancement and hyoid myotomy.

Midface advancement consists of fracturing each side of the face in the region of the upper jaw and both sides of the lower jaw, then essentially pulling the face forward a few millimeters. Metal spacers are then placed in the mid-face and the lower jaw to fill the gap between the bones. This surgery is reserved for patients with significant apnea untreatable with the other surgeries mentioned or CPAP. It has been reported to be highly effective in eliminating obstructive sleep apnea.

Tracheostomy is the oldest surgical treatment for OSA still in existence. It is done by making an incision in the lower neck and penetrating the trachea. A plastic or metal tube is then inserted through the skin into the trachea. This procedure is curative for OSA essentially in 100% of the patients. The tracheostomy site bypasses the area of obstruction during sleep. The tracheostomy can be covered during the day and opened at night. Because newer treatments have proven their effectiveness, tracheostomy is now rarely used for OSA.

Obstructive Sleep Apnea, Surgery reprinted with permission from sleepdisorderchannel.com
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