The Current State of Surgical Treatment for Obstructive Sleep Apnea

By David Upton, MD, FACS

Obstructive sleep apnea (OSA) is an increasingly common disease now affecting 26% of adults between the ages of 30-70 in the United States. Left untreated, it contributes to impaired cognition, hypertension, cardiovascular disease, and stroke. While positive airway pressure (PAP) remains the initial recommended therapy, patient adherence can be highly variable (32-90%). Recent advances in surgical techniques to address the site of upper airway obstruction have bolstered outcomes data reinforcing the vital role of surgery in PAP-intolerant patients.

Which patients are appropriate for evaluation by a sleep surgeon?
  • Any patient who has some degree of OSA diagnosed on sleep study and has undergone an unsuccessful trial of PAP therapy can benefit from evaluation by a sleep surgeon.
What does the evaluation in the sleep surgery clinic consist of?
  • A comprehensive examination of the upper airway incorporating fiberoptic endoscopy with the patient upright and supine to help localize the site of obstruction. In certain patients we will also incorporate “drug-induced sleep endoscopy” in coordination with our anesthesia colleagues to help better guide the therapeutic approach.
What surgical options exist for patients?

The surgical intervention is tailored to each patient based on their site of obstruction and often addresses multiple sites during the same operation:

Nasal: The main goal of nasal surgery in OSA is to improve obstructive symptoms by addressing the septum, nasal valve, and/or sinuses to help facilitate continued use of PAP therapy or mandibular advancement device therapy.

Oropharynx: The goal of oropharyngeal surgery is to open the lateral pharyngeal ports to allow improved airflow during sleep and includes tonsillectomy and soft palate muscle reconstruction.

Base of Tongue: The goal is to elevate the tongue base to expand the airway during sleep and can be accomplished with an oral appliance or implantable upper airway stimulation therapy.

What is implantable upper-airway stimulation therapy?

Hypoglossal nerve stimulation is an FDA-approved therapeutic surgical option for patients with moderate to severe OSA intolerant of PAP therapy and a normal body mass index that relieves obstruction at the level of the tongue base and palate. The surgery involves implantation of programmable neurostimulator in the chest with a stimulator placed on the hypoglossal nerve allowing tongue protrusion and sensory lead placed in the chest allowing for synchronization with breathing.

Any non-surgical treatment options for OSA besides PAP therapy?
  • Positional therapy to avoid supine sleep
  • Oral appliance therapy (aka mandibular advancement device)
  • Weight loss
Will insurance companies cover this therapy for my patient?

In general, both appliance therapy and surgical procedures are covered for OSA patients provided they have a clinically documented unsuccessful trial of PAP therapy. Members of the sleep surgery clinical team can assist patients and referring providers with any questions regarding insurance coverage.

For more information:

To learn more about sleep surgical options for OSA or to refer a patient call the UW Health Ear, Nose and Throat Clinic at (608) 287-2500.