Obstructive Sleep Apnea Syndrome: Surgical Therapy

The following surgeries can be performed for obstructive sleep apnea syndrome:

  • Interstitial radiofrequency therapy (RFT) of the turbinate, soft palate, palatine tonsils, and base of the tongue* .
  • Soft palate implants*
  • Laser assisted soft palate surgery* *
  • Radiofrequency uvulopalatoplasty* * – gentle surgical method for permanent tightening of the soft palate and shortening of the uvula.
  • Uvula capping (capping of the uvula)* * .
  • Uvulopalatopharyngoplasty (UPPP) – tightening of the uvula (uvula) and pharynx (pharynx; here: tightening of the soft palate muscles).
  • Maxillomandibular osteotomy (maxillomandibular rearrangement osteotomy, MMO) – severing of the jawbone: this allows the upper and lower jaw to be displaced forward.
  • Stimulation of the hypoglossal nerve during sleep (see below and under “Further therapy/cranial hypoglossal nerve stimulation of the upper respiratory tract).

* Celes as minimally invasive surgical methods [S2e guideline]* * Celes with limitation as minimally invasive surgical methods [S2e guideline].

Guideline Recommendations [S2e Guideline]

  • Nose: In cases of nasal airway obstruction and corresponding pathologic-anatomic correlate, nasal surgery is recommended to treat this condition. However, isolated nasal surgery does not usually result in a sufficient reduction in AHI, so nasal surgery should not be recommended for the primary treatment of OSA (OCEBM recommendation grade B). In contrast, nasal surgery may be considered as an improvement to CPAP therapy. (OCEBM recommendation grade C). Following nasal surgery, consideration may be given to reintroducing the CPAP device immediately after adequate swelling of the endonasal mucosa has subsided and the nasal framework is stable. Consideration may be given to re-titration of CPAP pressure during polygraphy or polysomnography (OCEBM recommendation grade D).

  • Nasopharyngeal (nasopharyngeal) surgery: regarding nasopharyngeal surgery in adults, no clear recommendation can be made at this point due to lack of data. In terms of expert opinion, endoscopic detection of pathologic changes in the nasopharynx by sleep medicine diagnosis and surgical removal of space-occupying lesions in the nasopharynx can be considered (OCEBM recommendation grade D).
  • Tonsils (tonsils in the oral cavity and pharynx): tonsillectomy may be considered as a therapy in non-tonsillectomized patients who are scheduled for surgical treatment of OSAS (OCEBM recommendation grade C).
    • Tonsillotomy (TE) in adulthood may be appropriate in individual cases (OCEBM recommendation grade D). The goal should be to reduce the volume of the tonsils as much as possible.
    • Only infants with moderate OSAS benefit from adenotonsillectomy (adenotomy + tonsillectomy/ tonsillectomy; T + A), whereas those with mild OSAS also benefit from waiting.
  • Interstitial radiofrequency therapy (RFT) to the tonsils: RFT of the tonsils may be useful in individual cases (OCEBM recommendation grade D).
  • Soft palate: UPPP with tonsillectomy is recommended for the treatment of OSA with appropriate pathoanatomic findings (OCEBM recommendation grade B). Success rates at 6 months are between 50% and 60% in most studies with patient selection. Long-term success rates are lower and vary between 40 and 50%.Mucosal resecting procedures without plastic sutures (uvulopalatoplasty, UPP): In agreement with AASM, mucosal resecting procedures on the soft palate without plastic sutures (e.g., LAUP) should still not be indicated for the treatment of OSA (OCEBM recommendation grade B). Soft palate interstitial radiofrequency therapy (RFT): soft palate radiofrequency surgery may be considered for mild-grade OSA (OCEBM recommendation grade B).Radiofrequency-assisted uvulopalatoplasty (RF-UPP): RF-UPP may be considered for mild- and moderate-grade OSA (OCEBM recommendation grade B).Soft palate implants: Soft palate implants can be recommended for mild OSA without anatomical abnormalities up to a BMI of 32 kg m-2 due to their minimally invasive nature (OCEBM recommendation grade B).
  • Tongue base and hyppharynx: radiofrequency therapy (RFT) of the tongue base: the method can be considered as monotherapy for the treatment of mild and moderate OSA (OCEBM recommendation grade B). Hyoid suspension, hyoidothyroidopexy: hyoid suspension may be considered as an isolated measure for OSA with suspected obstruction in the tongue base area (OCEBM recommendation grade C).Tongue suspension: the method may be considered for the treatment of mild to severe OSA, especially when used in multilevel surgery (OCEBM recommendation grade C).
  • Partial resection of the base of the tongue: resections at the base of the tongue may be considered as a treatment for OSA (OCEBM recommendation grade B).Stimulation of the hypoglossal nerve during sleep (see “Further Therapy/Cranial Hypoglossal Nerve Stimulation of the Upper Airway” below): Respiratory synchronous stimulation of the hypoglossal nerve may be recommended for moderate to severe OSA and ineffectiveness or intolerance of CPAP therapy (OCEBM recommendation grade B).Continuous stimulation may be considered in the absence of alternative therapies (OCEBM recommendation grade C).

Further notes

  • A new surgical procedure for patients with moderate upper airway collapse is unilateral upper airway pacemaker implantation (cranial hypoglossal nerve stimulation of the upper airway). This pacing system results in respiratory-triggered neuromuscular stimulation of the hypoglossal nerve with consecutive contraction of the genioglossus (“chin-tongue”) muscle. Its activation has a dilating effect, preventing collapse of the upper airway muscles and thus obstructive sleep apnea.A study showed that after 12 months for patients treated with this method, this resulted in a 68% decrease in the mean apnea-hypopnea index (AHI) from 29.3 to 9.0 events per hour. The oxygen desaturation index (ODI) even decreased by 70% from 25.4 to 7.4 events per night. This resulted in a significant reduction in daytime sleepiness and improved quality of life.
  • A bicenter randomized controlled clinical trial demonstrated that 90% of patients with obstructive sleep apnea who underwent tonsillectomy with uvulopalatopharyngoplasty (TE-UPPP) within 1 month had a reduction in the apnea-hypopnea index (AHI). The collective of those so treated was shown to be superior to the non-treated control group in terms of daytime sleepiness and snoring.Complication rate: 2 of 39 operated had postoperative rebleeding. After surgery, 35, 5% percent of patients continued to have obstructive sleep apnea requiring therapy.
  • However, the surgical procedures listed are not the first-line therapy. They should only be recommended if CPAP positive pressure ventilation is not tolerated. CPAP stands for “continuous positive airway pressure” and means that the affected person is ventilated at night via a breathing mask with positive pressure.