Surgical Treatment Options for Sleep Apnea: Understanding Procedures, Candidacy, and Potential Side Effects

Sleep apnea is the second most common sleep disorder, with an estimated more than 900 million cases worldwide. It causes breathing problems during sleep, and if left untreated, it can lead to serious health complications.

While the first line of treatment is usually Continuous Positive Airway Pressure (CPAP) and lifestyle modifications, some people require more intensive forms of treatment, including sleep apnea surgery. But many people with this condition are not very familiar with their surgical treatment options, which we’ll be talking about today!

In this article, we will go over the reasons why doctors may suggest surgical treatment for sleep apnea. We’ll explain the various types of operations that are available and discuss the methods your doctor may use to determine whether such procedures are right for you. We’ll talk about the things your doctor may ask you to do to prepare for surgery, along with what to expect on the day of, depending on the type of surgery you are having. We will also address some common concerns, including the potential side effects and complications. Plus, we’ll go over the treatment alternatives that your doctor may suggest if you are struggling with CPAP but are not a good candidate for surgery.

Each person with sleep apnea falls into one of the following three categories. Any surgery that your doctor suggests will largely depend on which group you are in.

• Obstructive Sleep Apnea (OSA): This condition arises when the muscles that line the mouth, throat, or upper airway become over-relaxed to the point that they collapse during sleep, preventing you from getting in a full breath of air. People with abnormal narrowing of the neck, nose, mouth, throat, or airway are often at a higher risk for developing OSA.
• Central Sleep Apnea (CSA): People who have CSA experience breathing issues due to a failure of the involuntary breathing process that takes over respiration during sleep. There are several reasons this may occur. In some cases, the brain may struggle to sense that you need more air. Or there may be a communication issue between the brain and the muscles that help you breathe. Other times it can be caused by the muscles themselves being unable to move for one reason or another. CSA is often a side effect of some other underlying condition that needs to be addressed.
• Complex Sleep Apnea: This form of disordered breathing occurs when someone who relies on respiratory support for OSA later develops CSA as well. The reason for this is not entirely understood.

If you are newly diagnosed with any form of sleep apnea, your doctor will likely encourage you to start out by making some lifestyle changes. In most cases, they will also suggest that you try sleeping with a Continuous Positive Airway Pressure (CPAP) machine. That said, there are some circumstances in which this type of treatment is simply not effective enough, or the individual cannot tolerate this type of respiratory therapy.

If this sounds familiar and/or you continue to experience breathing complications during sleep, with no other identifiable reason, your doctor may refer you to a specialist to see if your condition can be treated surgically. Additionally, some individuals may seek surgery if their sleep apnea is the result of some anatomical or physiological issue that can be easily repaired.

There are several different options for sleep apnea surgery. Each one can be categorized by the form of sleep apnea that they address. For those who require surgery for Complex Sleep Apnea, a combination of two or more different procedures may be appropriate in some situations.

OSA is often said to be a structural issue. Below are the main types of surgeries that can be performed on people who have sleep apnea caused by airway obstruction. Some are performed to enlarge the airway itself, while others are done to prevent collapse of the tongue, soft palate, throat muscles, etc.

Nasal Surgeries for Sleep Apnea

Certain nasal conditions can increase your risk of developing Obstructive Sleep Apnea. When the nasal passages are blocked for one reason or another, it can cause you to over-rely on mouth breathing while you are asleep, which oftentimes increases the likelihood of airway blockages caused by soft tissue collapse.

• Septoplasty: As the name suggests, deviated septums are characterized by a misalignment of the nasal cavities. However, they can be surgically realigned via a septoplasty procedure. During this, an ear, nose, and throat (ENT) surgeon will remove or realign the cartilage and/or bone that divides the affected part of the nasal septum. The goal is to create an equal amount of space on each side so that the nasal passages do not become blocked as easily.
• Turbinate Reduction: The turbinates are responsible for filtering the air that is brought in through the nose while also adding warmth and moisture to each breath that enters the body. But sometimes, these structures can take up too much space. In such situations, a surgeon will perform a turbinoplasty, or turbinate reduction, to reduce the size of these structures. As a result, each breath is able to move through the nasal passages and into the airway much more easily.
• Functional Endoscopic Sinus Surgery: This type of surgery can be performed in order to treat a number of causes of nasal and sinus blockages, including nasal polyps, chronic sinusitis, and even some small tumors. These procedures are usually relatively simple and involve removing the additional tissue that is causing the nasal blockage. They are often performed in a clinic with numbing medication.
• Nasal Valve Surgery: The nasal valve is responsible for directing airflow from the nose. When the valve becomes blocked or is unable to function correctly, it can lead to partial or full obstruction of the flow of air from the nose into the airway. This can be corrected by nasal valve surgery, which seeks to remove any tissue that is blocking the valve or restore function to the valve itself.

Throat Surgeries for Sleep Apnea

Certain components of the mouth, throat, and soft palate are more prone to causing airway blockages than others. This can be due to the fact that some areas are more likely to collapse during sleep, or it can be caused by oversized structures that impede the airway when lying down.

• Uvulopalatopharyngoplasty (UPPP): UPPP surgery is one of the most common surgical treatments for sleep apnea. This type of operation aims to reduce the amount of excess tissue located in or around the back of the throat. It typically involves surgically reducing the size of the uvula, soft palate, and/or tonsils in order to create extra room for airflow.
• Pillar Procedure: This procedure is considered to be a minimally invasive sleep apnea surgery. It involves the implantation of tiny rods into the soft palate, which is located at the top of the throat/very back of the mouth. These devices cause the surrounding muscles to stiffen so that they are less prone to collapsing into the throat and upper airway during sleep. Many experts suggest the the Pillar Procedure should be used as a stepping stone between CPAP and other, more invasive surgeries.
• Tonsil and/or Adenoid Removal: Compared to UPPP, this is a less common sleep apnea procedure for adults with lifestyle-related cases of sleep apnea. However, it is often very successful for those who have OSA due to enlarged tonsils and/or adenoids, especially in children. This surgery is relatively quick and easy compared to some of the others on this list. It involves removing the tonsils from the back of the throat, along with the adenoids located in the space where the sinuses meet the throat.
• Hyoid Suspension: The hyoid is a U-shaped bone that sits at the front of the neck, between the chin and thyroid cartilage. Its purpose is to provide an anchor point for the muscular structures surrounding that area, especially those that make up the tongue, voice box, and throat. In a hyoid suspension surgery, a small incision is made across the neck, and the bone is repositioned higher up, closer to the jaw. The idea is that this will provide the surrounding soft tissue with more stability so that it is less likely to collapse into the airway during sleep. Research suggests that this surgery is better paired with other OSA procedures.

Jaw Surgeries for Sleep Apnea

There are several types of jaw problems that have been known to contribute to the development of sleep apnea. Examples include conditions that impact the development or location of the lower jaw, head and face deformities, temporomandibular joint (TMJ) dysfunction, etc. However, outside of specific procedures that target these diagnoses, there is really only one type of jaw surgery that is performed with the sole purpose of treating Obstructive Sleep Apnea.

• Maxillomandibular Advancement (MMA): The purpose of an MMA procedure is to create additional space behind the tongue and towards the back of the throat in order to reduce the risk of collapse into the airway. It involves surgically moving the upper and lower jaws forward so that the tongue and soft palate are moved forward along with them.

Tongue Surgeries for Sleep Apnea

Tongue placement is a common cause of airway obstruction, which is why it is a popular target for sleep apnea treatments. Because it is attached more toward the back of the throat, it has a tendency to fall backward during sleep, which can cause a total blockage of the airway. While tongue surgeries can be done alone, they can also be performed alongside other sleep apnea surgeries.

• Genioglossus Advancement: The genioglossus muscle is responsible for the tongue’s ability to move forward and backward. It extends from the chin into the underside of the tongue. During this operation, the surgeon moves the genioglossus muscle forward, pulling the tongue forward along with it. Hence its second name, the “tongue base advancement.” This helps to prevent the tongue from being able to block the airway when lying down during sleep.
• Midline Glossectomy: This surgery, which is sometimes referred to as a “tongue base reduction,” involves removing any excess tissue from the base of the tongue. This helps to keep the airway open, even when you are asleep, because there is less tissue available to cause an obstruction. This procedure is usually performed alongside others, such as the UPPP surgery.

Airway Surgeries for Sleep Apnea

In some cases, the obstruction of the airway is so significant that traditional treatment options simply do not work. Oftentimes these cases involve some kind of underlying condition or injury that has led to such a serious blockage. In such cases, your doctor may suggest directly accessing the airway itself rather than trying to prevent airway obstructions from occurring in the first place.

• Tracheostomy: The purpose of a tracheostomy is to create another access point for air to enter the lungs. It involves making an incision into the neck and then the windpipe and then inserting a small tube with a vent for air to flow through. While tracheostomies are often done in emergency situations, they are less commonly performed for OSA due to the potential risks involved. However, they are helpful in situations where the level of airway blockage is very severe or cannot be treated by other means.

Stimulation Devices for Sleep Apnea

If your sleep apnea is the result of neurological or muscular issues rather than a natural narrowing of the throat or airway, it may be beneficial to simply prevent said muscles from collapsing. This is where stimulating implants come in!

• Hypoglossal Nerve Stimulation System (HNS): HNS devices are a relatively new type of solution for sleep apnea. It involves the implantation of a nerve-stimulating device just under the skin along your chest. It acts similarly to a pacemaker, stimulating the hypoglossal nerve, which controls the movement of the tongue and other muscles along the airway. This act of stimulation prevents said muscles from fully relaxing to the point that they cause airway blockages during sleep. One common example of this is the Inspire device.

Because CSA generally arises due to a problem with the brain, nerves, or muscles involved in breathing, there aren’t too many surgeries that can be done to treat this form of sleep apnea. Currently, the main option for surgical treatment is the implantation of a nerve stimulation device. That said, as we have mentioned previously, Central Sleep Apnea is often caused by some sort of underlying condition that may also require its own type of surgical treatment. Examples include brain tumors, strokes, injuries, etc.

• Phrenic Nerve Stimulation (PNS): The phrenic nerve is responsible for controlling the movement of the diaphragm. This is the main muscle involved in inhalation and exhalation. It also acts as a sensor for the brain, which means it plays a role in the brain’s ability to detect when and how to breathe. In the case of CSA, this line of communication can become disrupted. This is where a PNS comes in handy. This device stimulates the phrenic nerve, allowing the diaphragm to continue working, despite the existing issues. It is implanted in the chest and is designed to function only when you are asleep so that it does not interfere with normal breathing when you are awake. It includes a wire that stimulates the nerve directly in place of the brain. But it also has a second wire that senses your breathing patterns.

In order to determine whether you are a good candidate for sleep apnea surgery, your provider will start by discussing the reasons why your current treatment plan is not working for you. It may be helpful to document the troubles you have been experiencing, similar to a sleep diary. You should also expect to be asked about any previous treatments you have tried as well, if applicable.

By this point, your doctor should already know whether you have Central or Obstructive Sleep Apnea, but they will likely want to examine you further to identify any potential anatomical or physiological issues that may be contributing to your condition.

If your doctor feels that your concerns cannot be addressed using other, less invasive methods, they may choose to perform a couple of tests to establish whether surgery is a good option for you. This process will most likely include some of the same types of studies that you previously underwent during your initial diagnosis. They may also order new tests in order to better understand the cause and extent of your sleep apnea.

The process for determining your candidacy for surgical treatment may include the following:

• Physical Exam: Your provider will likely want to perform another physical exam to check for any anatomical issues that may be contributing to your sleep apnea. Of course, this is more relevant if you have airway obstruction rather than CSA.
• Imaging Tests: The doctor may order an MRI or CT scan in order to get an even better idea of any anatomical or physiological issues that may be causing or adding to your sleep apnea.
• Follow-Up Sleep Study: You will probably be asked to undergo another sleep study in order to determine how well you are responding to your current treatment plan. This time you will most likely be asked to do so while sleeping with your current form of sleep apnea therapy, such as a CPAP or your sleep apnea mouthguard.
• Endoscopy/Nasopharyngoscopy: This involves the insertion of a small camera into the mouth or nose in order to get a clear visual of the throat and upper airway. This may be done while you are awake, but it can also be performed during sleep. The purpose of doing this type of study while you are asleep is to hopefully catch the cause of your Obstructive Sleep Apnea as it is actively happening. While such tests aren’t always necessary, particularly in Central Sleep Apnea cases, they can be incredibly helpful in identifying those who are a good candidate for surgery.
• Ruling Out Other Causes: If you are not responding to your sleep apnea treatment, your doctor may want to rule out other potential causes, such as ones that are not surgically treatable or those that may be caused by underlying conditions. This may include a lung function test, blood work, imaging scans, and more.

The preparation for your surgery will most likely depend on the type of procedure that you are undergoing. Your surgeon may wish to get additional scans or scope images of your neck, mouth, and/or throat so that they can have an updated image that they can reference when planning and performing the operation. Also, if applicable, your provider will likely encourage you to make some lifestyle changes in preparation for surgery. Things like weight loss and quitting alcohol or smoking can increase the odds of your surgery being successful.

Your doctor’s office will most likely advise that you follow the standard preop guidelines. The list you will be provided may include at least some or even all of the following requests:

• Stop taking blood thinners, including ibuprofen and/or aspirin, ahead of your surgery.
• If you are going under general anesthesia, do not eat or drink after midnight. Some procedures may not require you to avoid food for more than a few hours, especially if you are only going under light sedation.
• Take a shower the night before or the morning of.
• Leave your jewelry and other valuables at home.
• Arrive with someone who can drive you home.
• Bring a list of your allergies and current medications.
• Document any postoperative directions.
• Wear comfortable shoes and clothing that you can change in and out of easily.

Technically there is no one specific surgery for sleep apnea. Your experience will entirely depend on the specific surgery you are having. Some of the different factors to keep in mind include:

• Inpatient vs. Outpatient: If you are undergoing an inpatient surgery, you should expect to remain in the hospital for monitoring for at least one night following your procedure. Outpatient surgeries allow you to go home on the same day, usually within hours of waking up.
• Operating Room vs. Procedure Room: If your surgery requires you to undergo general anesthesia, you will typically do so in a sterile operating room. The same goes for particularly risky surgeries. This can take place at either a hospital or at an outpatient surgical clinic. On the other hand, if you require light sedation or only local anesthetic, you will most likely be escorted to a procedure room, which usually does not have advanced monitoring capabilities.
• General Anesthesia vs. Sedation vs. Local Anesthetic: General anesthesia involves a complete loss of consciousness and sensation. Patients who undergo this level of anesthesia typically require respiratory support and close monitoring of their vital signs. There are different levels of sedation. They range from deep sedation to simply being given anti-anxiety medications. Conscious sedation falls into this category and allows patients to respond to stimuli and follow simple directions. However, most people are unable to recall the experience afterward. Local anesthetic references the use of numbing medications or techniques in the general area being worked on. It can be used along with anesthesia or sedation, or it can be performed by itself.
• Invasive vs Non-Invasive: Undergoing an invasive surgery means that your skin and tissue will be cut open in order to access the area in question. These operations usually require general anesthesia and often have longer recovery times compared to non-invasive alternatives. Meanwhile, non-invasive surgeries refer to procedures that do not require making large cuts or punctures in the skin. This often involves the use of lasers, radiofrequency ablation, and/or scopes to achieve the desired result.

Just like any other procedure, there are possible complications associated with each type of sleep apnea surgery. As a general rule, the more invasive a surgery is, the higher the risk level. The same trend goes for any operations that require general anesthesia due to its potential effects on your breathing.

Of course, your side effects also depend on the location of your procedure. Surgeries that impact the soft tissue of the nose, neck, mouth, throat, and/or airway will have increased risks for complications that are localized to those areas. On the other hand, nerve stimulators can have their own risks associated with their location and/or potential malfunctions.

Some of the risks associated with these types of surgeries include, but are not limited to, the following:

• Excessive bleeding
• Infection
• Blood clots
• New breathing problems
• Urinary retention
• Allergic reaction to anesthesia
• Injury to teeth, tongue, soft palate, etc.
• Difficulty swallowing
• Loss of sensation in the affected area
• Weakness of the adjacent muscles
• Nerve injuries

If you are struggling to continue sleeping with your CPAP machine but are not a candidate for surgery, you still have options! Additionally, if you are satisfied with your current treatment plan, but want to increase its effectiveness, many of these solutions can be used together with CPAP or surgery.

• Oral Appliance Therapy: These include sleep apnea mouthguards that adjust the position of the jaw and/or tongue or soft palate lifters to keep the soft palate from collapsing into the airway.
• Positional Therapy: Some people find that sleeping on their side or propped up reduces the severity of their sleep apnea they experience each night. This is because sleeping in these positions changes the additional effect that gravity has on the soft tissue that causes airway obstructions.
• Lifestyle Changes: One of the best ways to manage your sleep apnea is to reduce the number of risk factors that apply to you. Studies show that weight loss, limiting alcohol, avoiding opioid medications, and quitting cigarettes are all great ways to minimize the severity of your sleep apnea.
• Other Positive Airway Pressure (PAP) Machines: Sometimes, you need more than the standard CPAP to address your sleep apnea. And in other cases, CPAP may cause added breathing difficulties when trying to exhale against the flow of oxygen. In such cases, PAP therapy may still be appropriate, but you may simply need a different kind of device. Alternatives include Automatic Positive Airway Pressure (APAP), Bi-Level Positive Airway Pressure (BiPAP), or Adaptive Servo Ventilation (ASV).

Want to know more? Here are some common questions that people tend to have regarding surgery for sleep apnea!

The success rate of sleep apnea surgery depends on a lot of factors, including the type of surgery performed and the individual themselves. Generally speaking, these surgeries are often successful when the appropriate type of surgery has been performed. For example, UPPP surgery is believed to be over 80% successful when performed on the appropriate patient. But it can be as low as 8% in obese patients who have mid to large-sized soft palates.

The potential downsides of having surgery for sleep apnea include many of the same potential effects associated with having any other type of surgery. These include a heightened risk for bleeding, infection, blood clots, and breathing problems. Other risks that are specifically related to having a sleep apnea procedure include injury of the surrounding soft tissue, nerve damage, and additional muscle weakness in the surrounding area.

During the procedure, you should not feel any pain. Depending on which surgery you are having, you will undergo general anesthesia, sedation, or receive a local anesthetic. As far as recovery goes, the pain that comes after sleep apnea surgery depends primarily on the level of invasiveness of the operation. Some surgeries can take several weeks to recover from, while others are resolved within days.

It is possible to have your Obstructive Sleep Apnea cured following surgery, however, this isn’t necessarily always the case. For example, if your sleep apnea is caused by enlarged tonsils, taking those tonsils out will most likely resolve your OSA. However, if enlarged tonsils are only a part of the reason you are experiencing airway obstruction, having them removed may improve but not cure your sleep apnea altogether.

If you continue to struggle with sleep apnea after making lifestyle changes, sleeping with a CPAP, and trying other alternative solutions, you know how frustrating it can be just trying to find what works for you. If this sounds familiar, it may be time to talk to your doctor about surgical treatments for sleep apnea.

If you have OSA, you have a lot of options, including those that create more room in the airway, prevent the soft tissue from causing blockages, or stimulate the muscles so that they cannot become over-relaxed to the point of collapsing. And while there are fewer surgical treatments for CSA, phrenic nerve stimulation has also shown promising results in recent years.

So, if you’re ready to make a change, schedule an appointment with your doctor to discuss your concerns. Even if surgery isn’t the right choice for you, there may be other solutions out there that can help you get the high-quality sleep you need!