Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.
Definitions
Obstructive sleep apnea or sleep apnea is defined as either cessation of breathing (apnea) for 10 seconds, or a decrease in normal breathing (hypopnea) with an associated desaturation in oxygen and arousal during sleep that lasts at least 10 seconds. In adults, it is typical to have up to 4.9 events per hour. In obstructive sleep apnea, affected individuals are categorized based on how many apneas or hypopneas (apnea-hypopnea index or AHI) or events they have per hour.
Normal: <5 events per hour
Mild: 5 to <15 events per hour
Moderate: 15 to 30 events per hour
Severe: >30 events per hour
The Wisconsin Sleep Cohort Study, a longitudinal study of the natural history of obstructive sleep apnea (OSA), found that of a random sample (602 employed men and women, 30–60 years old) the prevalence of OSA (5 or more events/hr) was 9% for women and 24% for men. However, the study found that among sleepy patients in this group, 2% of women and 4% of men met criteria for obstructive sleep apnea syndrome (OSAS). Those who snored habitually, were more likely to have an AHI of 15 or more.
Clinical results
Most obstructive sleep apnea sufferers have multiple points of obstruction in their airway and therefore require multilevel sleep surgery in order to maximize the efficacy of treatment. A systematic review of the literature and meta-analysis showed that multilevel sleep surgery achieves a 60.3% apnea hypopnea index (AHI) reduction. This reduction in sleep apnea severity via surgical means compares well against the AHI reduction for best case CPAP patients where an overall AHI reduction of 66% was achieved. Even single level surgical intervention in sleep apnea, which demonstrates a lesser degree of AHI reduction, showed a 31% survival benefit when compared against those using CPAP as therapy.
In children
Children with obstructive sleep apnea typically have enlarged tonsils and adenoid tissue. Surgery on children is over 80% successful by simply performing an adenoidectomy and tonsillectomy. Those less likely to benefit from an adenotonsillectomy are obese children and those with other medical problems, such as Down Syndrome.
A sub-group of children may have occult laryngomalacia, where the tissue directly above the vocal cords (epiglottis, arytenoids) collapses into the airway during sleep. These children may benefit from a supraglottoplasty to help prevent that tissue from collapsing into the airway.
Surgical procedures
In adults, various surgeries treat specific causes for nasal and soft palate.
Obstruction in adults is most often multiple level, so the most successful surgeries involve multi-level surgery.
Tonsillectomy and/or adenoidectomy
Some adults with large tonsils may be candidates for having their tonsils and/or adenoids removed either alone or in combination with other procedures, such as uvulopalatopharyngoplasty (UPPP) or nasal surgery.
Uvulopalatopharyngoplasty (UPPP)
The procedure most commonly performed for sleep apnea is the uvulopalatopharyngoplasty (UPPP). This involves removal of the tonsils if still present, and a subsequent palatal procedure. The tonsil pillars are often sutured closed—and the uvula is either trimmed, cut, folded, reshaped, or sutured to the soft palate. Studies have shown that treatment effect of UPPP with tonsillectomy increases with tonsil size.
Hyoid suspension
Hyoid suspension, also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward in order to increase airway size and improve airway stability behind and below the base of tongue (retrolingual and hypopharyngeal region).
Genioglossus advancement
Genioglossus advancement (GA) also known as genial tubercle advancement (GTA), is a procedure that pulls the base of the tongue forward, usually to increase airway size due to deformity or a sleep breathing disorder. This procedure is frequently performed with either uvulopalatopharyngoplasty or maxillomandibular advancement surgeries.