Surgery for Obstructive Sleep Apnoea and Snoring

Overview

There is no single surgery or procedure that can treat all OSA.
EVERYONE IS DIFFERENT
Each individual patient case is the complex interplay of multiple areas of airway collapse and airflow dynamics. A particular operation might control one person’s OSA very well, but be completely ineffective in another.

In most cases, a “multi-level” surgical approach is required to adequately treat OSA/snoring.
This would normally mean surgery at the level of the nose, the palate and tongue/tongue base. Some procedures can be combined under a single anaesthetic, some are best delayed between surgeries or “staged”.

There is no substitute for a detailed clinical history, and comprehensive physical assessment.
Melbourne Sleep Surgery go to great lengths to ensure the right operation is offered to the right patient.

Goals of Surgery for OSA and Snoring:

  1. Treat OSA – minimise symptoms & risk
    In patients where more conservative approaches have failed or are unacceptable to the patient; surgery remains a sound option in the treatment of OSA.
    During your consultation we will discuss the goals, and likely outcomes of surgery at length with you before proceeding. Where surgery is chosen as the treatment option, we aim to minimize the medical risks of untreated OSA and relieve the symptoms being suffered.
  2. Facilitate use of CPAP mask, Mandibular Advancement Splint (MAS), other
    There are some patients where surgery alone will not adequately treat the risks of OSA, or the symptoms. In these patients, the operation may be targeted to help facilitate the use of CPAP or MAS for ongoing definitive management.

Surgery available for OSA/Snoring:

  • Nasal/sinus surgery
    In general, surgical treatment of the nasal airway alone is unlikely to have a large effect on the overall OSA, Sleep study scores, or snoring severity. However, where applicable can have significant positive outcomes in terms of symptom relief, be part of a multi-level surgical approach and facilitate use of other devices.Nasal surgery options include (normally a combination of):

    • Correction of deviated nasal septum (septoplasty)
    • Inferior turbinate surgery (turbinoplasty)
    • Removal of nasal polyps/opening of sinus drainage pathways (Functional Endoscopic Sinus Surgery: FESS)
    • Adenoidectomy
  • Palate Surgery
    Surgery to the soft palate (and potentially hard palate) is the most common surgery performed for OSA/snoring in adults. Removal of the tonsils (if still present) in combination with a form of “pharyngoplasty”/soft palate repositioning operation is the mainstay of palate surgery for OSA. These operations aim to better position the soft palate to limit collapse, and lessen snoring producing vibration.While there are many variations of this surgery described, the most common employed in our practice is the modified UvuloPalatoPharyngoplasty or mUPPP. As opposed to the older generation operations where significant amounts of soft palate tissue were resected or lasered (often with troublesome and unpredictable scaring), the mUPPP is an airway reconstruction procedure where no tissue is resected (except for tonsils and minimal amounts of palate fat) – and the palate is repositioned to a more favourable position – creating a more patent airway with less collapse.Occasionally, in severe OSA – we may not be able to get enough treatment effect from repositioning the palate soft tissues alone. In this setting, an operation termed Transpalatal Advancement (TPA) may be offered, where a segment of hard palate is mobilised (through the mouth) and advanced forward to further optimise palate position.Palatal surgery options include:

    • Tonsillectomy
    • Modified Uvulopalatopharyngoplasty (mUPPP)
    • Variations of mUPPP depending on anatomy
    • Transpalatal Advancement (TPA)
  • Tongue/Tongue Base Surgery
    Obstruction at the tongue and tongue base is another level of potential obstruction in OSA/snoring. Tongue/Tongue base surgery is most commonly combined with other levels of surgery. In some cases, the tonsil tissue at the base of the tongue (lingual tonsil) is large and obstructive and can be removed in a relatively non-invasive manner. In others, the actual bulk of the tongue muscle itself is the causative problem – a much more difficult problem to undertake/treat – in this setting tongue reduction surgery can be considered.
    In very rare circumstances the obstruction may be caused by tissues in the upper part of the voice box (larynx) – in particular the epiglottis or surrounding mucosa. Surgery to this area is also an option in selected cases. Tongue/Tongue Base surgery options include:
    • Lingual tonsillectomy
    • Midline glossectomy (tongue reduction surgery)
    • Tongue suspension surgery (rare)
    • Surgery to epiglottis/supraglottic airway (rare)
  • Nerve Stimulation
    One of the newest advances in OSA surgery is the development of implantable nerve stimulators. There are several of these devices available world-wide, each with subtle differences in the way they function. The device is implanted into the neck which stimulates the tongue to be brought forward while sleeping – minimizing collapse and improving airflow.In Australia, these devices are not yet commercially available – but the data from clinical trials is very promising. If you would like to know more, please ask.