Contemporary surgery for obstructive sleep apnea syndrome

Abstract

Surgical treatment of obstructive sleep apnea syndrome (OSAS) has been available in some form for greater than three decades. Early management for airway obstruction during sleep relied on tracheotomy which although life saving was not well accepted by patients. In the early eighties two new forms of treatment for OSAS were developed. Surgically a technique described as a uvulopalatopharyngoplasty (UPPP) was used to treat the retropalatal region for snoring and sleep apnea. Concurrently sleep medicine developed a nasal continuous positive airway pressure (CPAP) device to manage nocturnal airway obstruction. Both of these measures were used to expand and stabilize the pharyngeal airway space during sleep. The goal for each technique was to limit or alleviate OSAS. Almost 30 yr later these two treatment modalities continue to be the mainstay of contemporary treatment. As expected, CPAP device technology improved over time along with durable goods. Surgery followed suit and additional techniques were developed to treat soft and bony structures of the entire upper airway (nose, palate and tongue base). This review will only focus on the contemporary surgical methods that have demonstrated relatively consistent positive clinical outcomes. Not all surgical and medical treatment modalities are successful or even partially successful for every patient. Advances in the treatment of OSAS are hindered by the fact that the primary etiology is still unknown. However, both medicine and surgery continue to improve diagnostic and treatment methods. Methods of diagnosis as well as treatment regimens should always include both medical and surgical collaborations so the health and quality of life of our patients can best be served.

Keywords: Airway reconstruction; Contemporary surgery; Obstructive sleep apnea; Powell-Riley protocol.

Fig. 1

(A) is a 3-D CT taken awake and supine with software reconstruction specifically to assess characteristics of the airway. (B) is an axial section showing the minimum cross sectional area (MCSA) of the pharyngeal airway which measures 31.0 mm³. This is a significant narrowing at that level. (C) has a total airway volume of 23,372.2 mm³ from the inlet to the outlet outlined in pink. (D) is a reconstruction of the facial skeleton along with an outline of soft tissues. This allows an exposure of the airway that is not seen in traditional radiographs.

Fig. 2

Alar collapse during inspiration is very common in obstructive sleep apnea syndrome (OSAS). Alar grafts can improve patency when placed bilaterally along the alar rim.

Fig. 3

Genioglossus advancement. (A) Cadaver model with marking of rectangular cut on bone. (B) Rectangular cut (2×1 cm) with a thin sagittal saw from labial to lingual cortex to include the geniotubercle where the tendons of the genioglossus are attached. (C) Segment pushed gently into the floor of the mouth for hemostasis if needed. (D) Advance segment so the lingual cortex is pulled forward and turned enough so the lingual cortex is lying on the labial cortex. (E) The outer cortex is removed and a small titanium screw is placed at the inferior border. (F) Pre op. (G) Post op note the improvement of the airway space.

Fig. 4

Pre and post-op bi-max: 64 yr old male with severe Sleep Apnea Syndrome. Note improvement of the posterior airway space from bi-maxillary advancement.

Fig. 5

Forty one year old Asian woman, AHI 28.3, low sat 84%, severe EDS, BMI 22 kg/m²; surgical procedure for OSAS: BMA/GA with BMA advancement of 26 mm and GA advancement of 12 mm for a total advancement of 38 mm. Post op: AHI 2.5, low sat 91%, resolved EDS, BMI 21 kg/m². AHI: apnea-hypopnea index; EDS: excessive daytime sleepiness; BMI: body mass index; OSAS: obstructive sleep apnea syndrome; BMA/GA: bi-maxillary advancement/genioglossus advancement.