Surgical options for the treatment of sleep apnea carry risks but can be an effective alternative to CPAP or Comfrotable oral ap

This is partially taken from a blog on the http://www.IHATECPAP.com website. I think that it is important to have an understanding of the advantages and disadvantages to different surgical proceedure and also to understand how doing the wrong surgery first could create additional problems or morbidity when the most effective surgery is done. Before ever considering surgical proceedures patients should try both CPAP and/or oral appliances and possibly the new and exciting TAP-PAP combination therapy that allows treatment of extremely severe patients with more comfort by combining CPAP and oral appliance therapy.

In Children reduction and/or removal of tonsils and adenoids is a first line treatment and because we know permanent changes in brain development can result from pediatric sleep apnea time is of the essence. At the Baltimore American Academy of Dental Sleep Medicine meeting it was suggested that rapid maxillary expansion was also indicated in addition to surgical proceedures. This can be done as soon as the deciduous first molars erupt between 12- 18 months and certainly at two years old when second molars erupt. It is worth considereing doing the maxillary expansion prior to surgery to provide a better post surgical airway possibly reducing post-op complications.

In Adults it is no longer possible to do Rapid maxillary expansion but it is possible to widen the maxilla with a Schwartz (or similar) appliance. This will widen the mouth but not the nasal cavity. A surgical proceedure that is underused in adults is Rapid Maxillary Expansion with a surgical assist. This is a minimally invasive surgery that allows widening of both the oral and nasal cavities. It should be considered prior to nasal surgery because it may allow a single surgery to correct multiple problems.

Correction of deviated septums and enlarged turbinates should always be considered in chronic nasal congestion or blockage. Correction of a deviated septum without a partial turbinectomy can often move the problem nasal airway from one side to the other. Patients are almost universal in acceptance of procedures that dilate the nasal airway. Beware, Excessive reduction can be a problem. This is not a case where more is always better. There can be problems with over-aggressive turbinate removal that results in a condition called empty nose syndrome. It is described on Wikipedia as “Empty nose syndrome (ENS), also known as “the wide nasal cavity syndrome”, is a term coined by Dr. Eugene Kern of the Mayo Clinic(1994) to describe a rare and debilitating iatrogenic syndrome of chronic nasal physiological impairment following overzealous turbinate resections in the nose (turbinectomies).” I have never seen this in a patient but the process involves a concept of tidal volume vs air exchange. Tidal volume is the total air that moves in and out of the lungs but does not tell us how much oxygen is exchanged in the alveoli of the lungs. An experiment to feel this effect can be done by opening the mouth wide and breathing in and out without resistance. In less than a minute most patients will feel like they are suffocating. This is what happens to some patients having a panic attack and hyperventilating and will pass out from lack of oxygen. Patients are often given a paper bag to breathe in and out into. Patients exchange oxygen from the blood stream in the alveoli of the lungs not on inspiration but during expiration against resistance. Total removal of nasal resistance reduces turbulence on exhalation and though tidal volume flows in and out there is almost no oxygen exchange at the alveoli level. There is an extremely low risk of this problem occuring but additional information is available at http://en.wikipedia.org/wiki/Empty_nose_syndrome.

Removal of nasal polyps is both a simple and safe procedure. This cannot be said about soft palate surgery which can lead to more adverse results. Maxillomandibular surgery (MMA) is an important option for some patients with severe sleep apnea who are also CPAP intolerant. Some surgeries can create problems that make MMA surgery more difficult in the future. These other surgeries used to treat sleep apnea include UP3 or Uvulolopalatopharyngealplasty which has a very high morbidity rate and less that 50% of patients had a 50% reduction in apnea indexes and almost all patients still required either CPAP or oral appliances to treat residual apnea. Long term problems include multiple ear symptoms, swallowing problems, voice changes and velo-insufficiency with food and liquids entering nasal cavity. UP3 surgery has lost favor as a first line treatment. Alternatives to UP3 with lower morbidity were tried including LAUP or laser assisted uvuloplasty, often described as feeling like a blow torch was used in the throat and somnoplasty which is probably the most comfortable way to reduce the soft palate but requires several repeat surgeries and does not eliminate sleep apnea leaving patients still needing CPAP, Appliances or additional surgery. Pillar surgery involves placing stents in the soft palate and while it is relatively painless it is also useless for treating moderate to severe apnea but might be helpful for very mild apnea and/or simple snoring. Pilar surgery well ineffective does not create problems for future MMA surgery.

A newer soft palate surgical procedure involves using a sliding flap to advance the soft palate. The advantage to this surgery is that it is reversible. The biggest problem with soft palate surgeries is they increase the risk of velo-insufficiency following maxillary advancement. Because maxillary and mandibular advancement is the most effective surgical proceedure having a reversible soft palate surgery is vital. Tracheotomy is actually the single most effective surgery but is not accepted by most patients except in an emergency context. A tracheotomy lets the patient bypass the base of the tongue and breathe thru the throat. The base of the tongue and the epiglottis secondary to base of tongue pressure is the location of the majority of obstructive events. Surgery to reduce the tongue size or position include removing an anterior wedge from the tongue and letting the tongue posture forward, a median rhomboid glossectomy which removes a rhomboid shaped area from the center of the tongue. It is a challenging surgery and the physicians I have talked to have never done it more than once. I have never talked to who has had that proceedure. There are two prcoeedrures for reducing the Base of the tongue the radiofrequency or somnoplasty procedure has been shown to be as effective as the base of tongue surgery and is much easier on the patient. A paper comparing the procedures recommended that radiofrequency was preferred in spite of multiple procedures. Base of tongue reduction by either method may not cure apnea alone but will allow lower CPAP pressure and/or less advancement of the mandible for appliances therapy. It will have a positive effect relative to maxillomandibular surgery as well.

A less aggressive surgery than full maxillomandibular advancement is a genioglossus advancement. This involves cutting the chin loose from the lower jaw and bringing it forward and bolting it in place. I like to call this the “Jay Leno” surgery because everyone has the Jay Leno look after surgery. This is a good surgery for a patient with a weak or recessive chin but normal bite who would like to avoid more radical surgery. In these patients it can also be done in conjuction with maxillomandibular surgery.

Maxillomandibular advancement consists of cutting the upper jaw or maxilla loose from the skull and usually moving it downward and forward. In narrow maillas the surgeon may also cut the upper jaw into sections and then rearange the parts and either wire or bolt the bones together with titanium plates. The lower jaw is then cut into three pieces and the middle part is advanced and the parts are again either wired together or bolted with titanium screws and plates. The patient usually has the mouth wired shut for up to six weeks.

This is an extremely effective procedure and in some patients can be a cosmetic enhancement while in others it results in protrusive profile that is not acceptable. At this time I would say “let the buyer beware” This is a serious surgery and needs to be approached with caution and deliberation. I love the quote “THERE IS NO DISEASE OR DISORDER THAT CANNOT BE MADE WORSE BY STICKING A KNIFE IN IT.” and I wish I knew who first said it. It does not mean you should not do surgery but rather take a cautious and informed approach to any surgery and ask about possible problems associated with the surgery.

In the case of Maxillomandibular surgery for treating sleep apnea I strongly recommend that maximum advancement with oral appliances be done before any surgery. The TAP 1 is probably the most effective appliance at achieving this position. Utilize a daytime appliance to eliminate pain or discomfort from trying to return to the original bite. If apnea is eliminated with the appliance the surgeon now has a surgical guide to determine where to reassemble the patient after cutting the jaws into multiple pieces to get the best results. This is major surgery an patients do not want to need to Need CPAP, Appliances or additional surgey to treat their apnea after going though this extensive surgery.

An article in the Journal of Otolaryngologic Head and Neck Surgery in November of 2009 reported on “Complications/adverse effects of maxillomandibular advancement for the treatment of OSA in regard to outcome” (abstract below) They reported adverse advents as well as cosmetic changes but state the patients considered these secondary to the surgical outcome. The most common side effect was mental nerve damage. This would feel like a numb (paraesthesia) lower lip to the patient similar to the feeling of having anasthetic for a filling on the lower jaw. It is also possible to have tongue paraesthesia.

The results were very good with the “mean apnea-hypopnea index decreased from 65.5 +/- 26.7 per hour to 14.4 +/- 14.5 per hour. In simple English this means that patients began with apnea-hypopnea indexes of as high as 92 to as low as 38 and after surgery the AHI was reduced to 28 to Zero. The patients with apnea indexes in the upper ranges would still need CPAP but some of the 50 patients had a complete cure. This is an excellent and effective surgical option that carries risks of adverse events and cosmetic changes. It is possible to effectiveness by oral appliance advancement as a trial to evaluate the best position to reassemble the patient.

PubMed abstract:
Otolaryngol Head Neck Surg. 2009 Nov;141(5):591-7.
Complications/adverse effects of maxillomandibular advancement for the treatment of OSA in regard to outcome.
Blumen MB, Buchet I, Meulien P, Hausser Hauw C, Neveu H, Chabolle F.

ENT Head and Neck Surgery, Foch Hospital, Suresnes, France. mbjblu@club-internet.fr
OBJECTIVE: To evaluate adverse effects/postoperative complications and surgical response rate of maxillomandibular advancement for the treatment of severe obstructive sleep apnea syndrome. STUDY DESIGN: Case series with chart review. SETTING: Otolaryngology Head and Neck Surgery Department in a teaching hospital. SUBJECTS AND METHODS: A total of 59 consecutive severe sleep apnea patients underwent maxillomandibular advancement. Systemic complications were evaluated from medical charts. Functional adverse effects and cosmetic consequences were evaluated by questionnaires. The treatment outcome was assessed by polysomnography. RESULTS: Fifty patients were evaluated. They had a mean age of 46.4 +/- 9.0 years. No serious postoperative complication was observed. The most frequent local complication was mental nerve sensory loss. Most patients reported cosmetic changes. The mean apnea-hypopnea index decreased from 65.5 +/- 26.7 per hour to 14.4 +/- 14.5 per hour (P < 0.0001). Light-sleep stages were also decreased (P < 0.0001), whereas deep-sleep stages were increased (P < 0.001). CONCLUSION: Maxillomandibular advancement can induce local adverse effects and cosmetic changes, but they seem to be considered as secondary to the patients according to the surgical outcome. PMID: 19861196 [PubMed - indexed for MEDLINE]