INTRODUCTION — Obstructive sleep apnea (OSA) is a disorder characterized by obstructive apneas and hypopneas due to repetitive collapse of the upper airway during sleep. Untreated OSA is associated with symptoms of excessive daytime sleepiness, impaired daytime function, metabolic dysfunction, and an increased risk of cardiovascular disease and mortality.
In most adults, first-line therapy for OSA consists of behavioral modification, including weight loss if appropriate, and positive airway pressure (PAP) therapy [1-3]. For patients who fail or do not tolerate PAP therapy, treatment options include oral appliances and surgical therapy. The choice among various second-line options depends on the severity of the OSA and the patient's anatomy, risk factors, and preferences.
Surgical treatment of OSA includes a wide array of procedures and approaches that enlarge and/or stabilize the upper airway. These procedures can be categorized as nasal, upper pharyngeal, lower pharyngeal, and global upper airway procedures. Careful patient and procedure selection, especially related to the anatomy, physiology, and function of the upper aerodigestive tract, and perioperative risk management are important considerations in the surgical evaluation of patients with OSA.
This topic will review the roles of surgery in the management of OSA, appropriate patient and procedure selection, and types of upper airway surgery used in the treatment of OSA. The diagnosis and management of OSA more generally are discussed elsewhere. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Management of obstructive sleep apnea in adults" and "Oral appliances in the treatment of obstructive sleep apnea in adults".)
ROLES OF SURGERY — Surgery is usually reserved as a second-line therapy for obstructive sleep apnea (OSA), either as secondary therapy in patients with OSA who cannot adhere to continuous positive airway pressure (CPAP) or as adjunctive therapy along with CPAP or an oral appliance [4]. Surgery is rarely indicated as primary therapy in adults; this contrasts with children, in whom adenotonsillectomy is generally considered first-line therapy for moderate-to-severe disease in the presence of adenotonsillar hypertrophy. (See "Management of obstructive sleep apnea in children".)
●Secondary role – Surgery can provide secondary treatment for patients not adequately adhering to CPAP therapy despite adequate troubleshooting. (See "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea", section on 'First-line interventions'.)
While there is no consensus on what constitutes CPAP failure and warrants secondary surgery, surgical consultation should be considered for inadequately treated patients with mild symptomatic, moderate, or severe OSA. Surgical therapy in such cases may include multiple staged procedures or single-stage combined procedures. (See 'Surgical outcomes' below and 'Specific procedures' below.)
●Adjunctive role – CPAP is most effective when it is used regularly and for the majority of the sleep period [5-7]. Adherence with CPAP is suboptimal in many patients, however, and this limits effectiveness. (See "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea".)
Some patients struggle to use CPAP due to obstructing anatomy (eg, nasal obstruction, severe tonsillar hypertrophy) that can reduce nasal interface tolerance or mandate high therapeutic pressures [8-11]. Likewise, nasal resistance may compromise the treatment efficacy of oral appliance therapy [12]. By lowering the pressure requirement of CPAP or alleviating nasal resistance, surgical enlargement and stabilization of the airway may enable the patient to succeed with CPAP [11,13-16] or oral appliance.
The surgical goal in these situations is to improve CPAP or oral appliance effectiveness. The specific surgical procedure depends on the site(s) of anatomic obstruction (eg, turbinate reduction to address obstructing turbinate hypertrophy). (See 'Procedure selection' below.)
●Primary role – Surgical treatment is indicated as a primary therapy for OSA when a fixed, surgically correctible airway obstruction is responsible for the apnea [1]. The main example of a correctible, obstructive lesion is tonsillar hypertrophy. Tonsillectomy is used as primary therapy in patients with severe tonsillar hypertrophy or as adjunctive therapy in patients needing high CPAP pressures. (See 'Tonsillectomy' below.)
PATIENT SELECTION — Surgical candidacy in patients with obstructive sleep apnea (OSA) depends on three main factors: patient desire for surgery, existence of a surgically correctible problem, and fitness for surgery.
●Desire for surgery – First, the patient must desire surgical therapy after being informed of the expected benefits and risks. Surgery is not advisable for patients who have unrealistic goals or expectations of surgery. Surgery is rarely a complete cure for OSA, and some patients may not derive any noticeable benefit. (See 'Surgical outcomes' below and 'Specific procedures' below.)
●Surgically correctible problem – Most patients with OSA have some degree of anatomic abnormality, but not all anatomic abnormalities are conducive to surgical therapy. Occasionally, the source of obstruction is only evident during an examination while asleep or sedated. Comprehensive evaluation by an experienced surgeon, including direct visualization of the airway with or without sedation and upper airway imaging in selected cases, is critical in determining surgical candidacy. (See 'Laryngoscopy' below and 'Craniofacial and upper airway imaging' below.)
●Fitness for surgery – As with all surgical procedures, patients must be deemed fit to undergo surgery and have adequate psychosocial support. Greater degrees of comorbidity increase surgical, anesthetic, and perioperative risks. Although there are no absolute criteria to judge surgical candidacy with respect to comorbidity in patients with OSA, consideration of this issue plays a major role in surgical decision-making.
OSA itself is associated with an increased risk for complications from procedures with sedation, analgesia, and/or anesthesia. In addition, patients with OSA often have additional comorbidities (eg, hypertension, gastroesophageal reflux disease, diabetes, depression) that may, individually or in aggregate, impact surgical risk. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea", section on 'Perioperative complications' and "Preanesthesia medical evaluation of the patient with obesity", section on 'Preoperative evaluation'.)
Patients with severe comorbidity may be poor candidates for upper airway reconstructive surgery, which can require multiple or complex operations. Some of these same patients may be appropriate candidates for a less complicated procedure such as tracheotomy. (See 'Global upper airway procedures' below.)
SURGICAL EVALUATION — Upper airway surgery in patients with obstructive sleep apnea (OSA) should be performed in conjunction with a comprehensive preoperative assessment and follow-up plan. (See "Management of obstructive sleep apnea in adults".)
History — A complete medical history relevant to OSA is indicated for all patients. Clinicians should review the chief complaint as stated by the patient, the symptom burden of OSA to the patient and significant others (table 1), and the severity of OSA as measured with polysomnography or home sleep apnea testing (see "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Classification of severity'). All of these factors affect how aggressively patients may wish to pursue invasive treatment.
Some symptoms can help identify potential surgical approaches. For example, fixed nasal airway restriction, chronic mouth breathing, or morning dry mouth suggest nasal airway compromise that might benefit from anatomical correction. Recurrent uvular swelling, tonsillitis, or bothersome tonsillar pellets suggest a palatal or oropharyngeal source of obstruction that might be amenable to surgical correction. Food-sticking dysphagia at the mid-pharynx can be a symptom of lingual tonsillar hypertrophy, which can also contribute to OSA and be corrected with surgery. On the other hand, some other forms of dysphagia, such as nasopharyngeal reflux, may be relative contraindications for surgery.
The history should also include an assessment of the patient's past experience with continuous positive airway pressure (CPAP), an oral appliance, and/or weight loss. Some patients may have an unrealistic optimism for surgical treatment; others may not have had an adequate trial of CPAP and would benefit from advice to resume CPAP or other noninvasive treatments prior to considering surgery. Past experience with nonsurgical therapies can also impact the follow-up plan after surgery. (See "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea", section on 'First-line interventions'.)
Review of the past medical history is important, as the number and type of comorbidities impacts preoperative and perioperative management. As for other elective surgeries, preoperative consultation with a cardiologist should be considered for patients with significant cardiac risk. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
Physical examination — A thorough upper airway examination provides the anatomical basis of surgical decision-making. A full head and neck examination is performed, with a focus on the structures that impact the upper airway.
The nasal airway is evaluated in detail (figure 1). External and internal deformities and nasal valve compromise are examined with respect to nasal airflow. Nasal flow measurements, quantitative anatomical measurements (eg, acoustic rhinometry), and nasal endoscopic examination may all be indicated to supplement the nasal examination, depending upon examination findings [17]. Specific procedures are available for each type of abnormality of nasal airflow. (See 'Nasal procedures' below.)
A direct examination of the oral cavity and oropharynx provides insight into the potential role of uvulopalatopharyngoplasty (UPPP), tonsillectomy, and some tongue procedures. There are variants of UPPP to address various patterns of compromise to the oropharyngeal inlet and velopharyngeal port, depending on whether narrowing is in the superior-inferior dimension, lateral dimension, and/or anterior-posterior dimension. Signs of a large tongue, such as scalloping (dental indentations in the tongue) or modified Mallampati 3 or 4 (tongue obscures pharynx, comparable to Friedman Tongue Position IIb – IV (figure 2)), suggest a possible benefit from tongue reduction surgery. (see 'Upper pharyngeal procedures' below).
The lower pharyngeal and laryngeal airway is evaluated by indirect (mirror) examination and by inspection of other related structures in the neck and mouth. For example, the position of the hyoid bone relative to thyroid cartilage will determine if hyoid suspension to the thyroid cartilage is feasible. The height of the mandible will determine if genioglossus advancement is a viable option. The state and position of the teeth as well as the craniofacial examination influence surgical decision-making regarding mandible advancement or maxillomandibular advancement. (See 'Lower pharyngeal and laryngeal procedures' below and 'Global upper airway procedures' below.)
Laryngoscopy — Transnasal flexible laryngoscopy is indicated if the indirect examination does not provide an adequate evaluation of the lower pharyngeal and laryngeal airway, or to examine the lower pharyngeal and laryngeal airway with the tongue in its native position if lower pharyngeal obstruction is suspected.
Flexible laryngoscopy provides an excellent view of the entire upper airway, without the distortion created by anterior tongue retraction during the indirect examination. The anatomic findings dictate which type of tongue advancement/stabilization procedure is indicated, whether tongue reduction or lingual tonsillectomy is indicated, and whether epiglottis correction is needed.
During this exam, various maneuvers test collapsibility of the airway (eg, end-expiration hypotonic state, Mueller maneuver), identify vulnerability to nasal obstruction (eg, effect of mouth opening), and evaluate the anatomic effects of various surgical maneuvers (eg, mandible advancement). The procedure is best performed in sitting and supine positions in order to detect the positional effects on the airway.
If further evaluation is needed, then flexible laryngoscopy can be performed under drug-induced sedation (eg, propofol) and monitored anesthesia care to assess for occult sites and patterns of narrowing or obstruction. Drug-induced sleep endoscopy is most useful when the awake exam is not consistent with the polysomnography result (eg, normal exam and severe OSA). It has been shown to help predict surgical treatment success for some procedures [18,19], although prediction accuracy remains variable [20]. It can be useful to direct secondary site-directed procedures, and to assess the state of the airway after completion of site-directed therapies and before maxillomandibular advancement. Current US Food and Drug Administration (FDA) recommendations include sleep endoscopy to determine eligibility for upper airway stimulation therapy [21,22], but other surgical procedures do not mandate drug-induced sleep endoscopy. (See "Upper airway imaging in obstructive sleep apnea in adults", section on 'Nasopharyngoscopy and drug-induced sleep endoscopy' and 'Global upper airway procedures' below.)
Craniofacial and upper airway imaging — Imaging helps with surgical planning, especially for procedures involving osteotomies. An orthopantogram (mandible) radiograph reveals the state and position of the tooth roots, bony height of the mandible, the position of the mental nerve foramina, the presence of bony pathology, and the position of the condyles. A lateral cephalogram provides documentation of relative skeletal positions. Craniofacial and airway computed tomography (CT) scans provide details of the nasal structures, sinuses, mandible and dental dimensions, airway soft tissues, and other pathologic findings. (See "Upper airway imaging in obstructive sleep apnea in adults", section on 'Imaging modalities'.)
Awake or asleep magnetic resonance imaging (MRI) and computational fluid dynamics are experimental and not used routinely in the surgical evaluation of patients with OSA.
PROCEDURE SELECTION — Procedure selection takes into account multiple factors related to a patient's upper airway.
●Native anatomy and anatomic abnormalities. The main upper airway anatomic regions and structures relevant to obstructive sleep apnea (OSA) (table 2) and a sample of upper airway anatomic abnormalities that can be addressed surgically (table 3) are provided in the tables.
●The presence or absence of dynamic collapse. Examples of dynamic collapse include hypercollapsible segments (eg, nasal valve [23], palate, tongue, or epiglottis collapse) and variable obstruction (eg, positional turbinate hypertrophy). Many variations of uvulopalatopharyngoplasty (UPPP) have been designed to address different patterns of collapse. For example, expansion sphincter pharyngoplasty stabilizes lateral collapse [24], and palatal advancement pharyngoplasty addresses anterior-posterior compromise [25].
●Preservation of physiological functions. Depending on the specific procedure, surgeons may accomplish this by preserving the uvula to prevent velopharyngeal incompetence, retaining some inferior turbinate tissue to prevent atrophic rhinitis, and partial glossectomy focused in the midline to avoid injury to the lateral neurovascular bundle of the tongue.
Many surgeons take a site-directed, staged approach to surgical therapy. In this approach, primary sites of obstruction are usually addressed first with site-directed treatments. This approach uses the minimum amount of surgery to achieve the treatment goals.
●Pharyngeal compromise by narrowed lateral pharyngeal walls, enlarged tonsils, or enlarged uvula are the most common anatomic abnormalities [26], and collapse at the palate is the most common site [27]. Therefore, surgery addressing these issues (ie, variants of UPPP) is the most common surgery for OSA [28,29]. (See 'Upper pharyngeal procedures' below.)
●A third or more of patients will have lower pharyngeal and/or laryngeal obstruction, either alone or in addition to an upper pharyngeal obstruction [27,28,30]. Lower pharyngeal correction, which may require multiple surgical procedures, is therefore required in a substantial number of patients undergoing surgery for OSA. (See 'Lower pharyngeal and laryngeal procedures' below.)
●Nasal obstruction should also be addressed, as it causes more negative intrapharyngeal inspiratory pressures and collapse and can force mouth opening that compromises the pharyngeal airway [31-33]. Of note, there is some evidence to suggest that simultaneous nasal and pharyngeal surgery should be avoided to avert postoperative swelling in both areas at the same time [34,35]. (See 'Nasal procedures' below.)
Patients refractory to site-directed treatments may require global upper airway treatment [28]. Maxillomandibular advancement provides upper and lower pharyngeal airway stability simultaneously. This major procedure provides best results when following the site-directed treatments described above [36,37] or when there is maxillary or mandibular deficiency. (See 'Global upper airway procedures' below.)
PERIOPERATIVE RISK MANAGEMENT — There are inherent risks of anesthesia and surgery that are exacerbated in the setting of obstructive sleep apnea (OSA) [38,39]. A preoperative evaluation assesses these risks (eg, hypertension, obesity) to plan for optimal perioperative management.
Intraoperatively, the most important factor to protect the airway is awareness. Manual mandible advancement, positive airway pressure via the anesthesia mask, an oral airway, and a nasopharyngeal (ie, nasal trumpet) are all readily available in the operating room and are effective for maintaining the airway if obstruction occurs in a sedated patient prior to intubation or after extubation. Intubation can usually be performed directly, especially with the newer intubating videolaryngoscopes [40-42]. Since the airway is readily maintained with the techniques listed above, awake intubation, which is more difficult, is rarely necessary.
Before extubation, there must be complete reversal of neuromuscular blockade. Awake extubation results in fewer spontaneous obstructive apnea events; however, it must be done particularly carefully in order to avoid agitation, acute hypertension, bleeding into the airway, bleeding into soft tissues around the airway (ie, hematoma, itself a postoperative airway risk), laryngospasm, and traumatic extubation by the patient. Extubation while still deeply sedated is more comfortable for the patient and may be safer as long as the airway is maintained as noted above until the patient awakens sufficiently to maintain the airway spontaneously. Dexmedetomidine can facilitate safe extubation [43,44]. Anesthesiologist and surgeon communication is key for planning and maintaining a safe airway.
Intraoperative and postoperative blood pressure control helps reduce bleeding into the airway and soft tissues around the airway, so it is an important part of airway protection.
Postoperatively, appropriate disposition may vary according to the type of procedure, the type of anesthesia, the severity of OSA, the presence of comorbidities, the risk of significant airway swelling, and requirements for pain control. Patients with severe sleep apnea and/or those at risk of significant airway swelling are more likely to need airway monitoring postoperatively. Postoperative admission also facilitates the management of pain and hydration, both of which are particular challenges after upper airway surgery. Postoperative CPAP (when feasible) and/or aggressive head-of-bed elevation help protect the airway, especially when using sedating analgesic medications. Minimization of sedating analgesics (ie, opiates) reduces the risk of inducing worse OSA events or respiratory suppression postoperatively. Non-sedating analgesics should be substituted whenever possible; these include acetaminophen (IV when necessary), selective cox-2 inhibitors (eg, celecoxib), topical anesthetics (eg, viscous lidocaine), ice, and corticosteroids. Cox-2 inhibitors reduce opiate need [45] without inhibiting coagulation like other non-steroidal anti-inflammatory drugs [46,47]. Ice reduces pain, swelling, and bleeding after surgery.
Surgeons should educate patients preoperatively about these issues. Discussion points include the goal to minimize postoperative narcotics, the possible need for an intensive care unit stay, and the potential need for postoperative continuous positive airway pressure (CPAP) use. Patients who understand the risks and perioperative management plan will have less anxiety and an improved recovery.
These and other considerations for the preoperative, intraoperative, and postoperative management of patients with OSA are reviewed in detail separately. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea" and "Intraoperative management of adults with obstructive sleep apnea" and "Postoperative management of adults with obstructive sleep apnea".)
SURGICAL OUTCOMES — Surgical treatment for obstructive sleep apnea (OSA) provides long-term benefits in selected patients, although complete elimination of OSA is often not achieved. Patients and referring clinicians considering surgery must have realistic expectations of treatment benefit as well as an understanding of the range and frequency of side effects and complications.
Various surgical procedures have generally not been compared directly with one another, and surgical decisions are individualized based on patient anatomy and surgeon preferences. Available evidence for specific procedures and relevant adverse effects is summarized below. (See 'Nasal procedures' below and 'Upper pharyngeal procedures' below and 'Lower pharyngeal and laryngeal procedures' below and 'Global upper airway procedures' below.)
Systematic reviews of randomized trials involving surgery versus a control condition (eg, sham procedure, continuous positive airway pressure [CPAP], or observation) have identified a limited number of trials and significant heterogeneity in procedures and outcomes, precluding pooling of data [48,49]. Others have attempted to review the literature more broadly to include both observational studies and trials, but these reviews usually consist of small samples of these studies [50,51]. One challenge is that there are a variety of surgical procedures and indications, which makes it difficult to make broad generalizations based on these reviews. In addition, many studies do not mimic actual clinical practice, in that a single specific surgical procedure is studied rather than a combination of procedures modified for the specific patient. There are also inherent challenges in performing randomized trials for invasive therapies [52].
Acknowledging these limitations, the best available evidence suggests that surgery has a beneficial effect on OSA when patients are appropriately selected (see 'Patient selection' above and 'Procedure selection' above). Although the improvement in the apnea-hypopnea index (AHI) is often only partial, other outcomes such as snoring, daytime sleepiness, and quality of life improve in most patients. While multiple observational studies have reported an association between surgery and decreased mortality [53-56], this has not yet been tested in randomized trials, and more studies are needed to better characterize the potential long-term benefits of surgical therapy on cardiovascular outcomes and mortality.
Further study is also needed to define patient-level characteristics that predict benefit from surgery. In general, factors that may increase the likelihood of achieving a low AHI include lower baseline AHI, lower body mass index (BMI), and less complex obstruction (eg, no circumferential velopharyngeal collapse, single-level obstruction, large tonsils, no mandibular deficiency) [19,28,51,57-61]. Other predictors are procedure specific and less consistent.
SPECIFIC PROCEDURES
Nasal procedures — The primary utility of nasal procedures in the context of obstructive sleep apnea (OSA) is to relieve nasal obstruction as an adjunctive measure to improve outcomes with continuous positive airway pressure (CPAP), an oral appliance, or other surgery. Nasal procedures should not be used as a stand-alone therapy for treatment of moderate or severe OSA.
●Turbinate reduction – Turbinate reduction reduces obstruction caused by inferior turbinate hypertrophy, which is a common cause of nasal obstruction, especially related to recumbent position [17,62,63]. The goal of turbinate surgery is to reduce size without compromising mucosal function. Turbinate mucosa is important for humidifying, warming, and filtering air. Several methods are available for turbinate reduction (table 4).
●Septoplasty – Septoplasty improves the nasal airway by straightening a deformity of the nasal septum. Septal deformity compromises nasal breathing by physically obstructing airflow, creating airflow turbulence patterns that reduce airflow efficiency, or by promoting nasal crusting; compensatory turbinate hypertrophy on the contralateral side of a deviated septum often contributes as well [64]. Surgical correction of the septal deformity improves the nasal airway, and concurrent contralateral turbinate reduction results in further improvement [64]. Sometimes surgical reduction of the compensatory turbinate hypertrophy alone is sufficient to obtain an adequate nasal airway to improve CPAP tolerance.
●Nasal valve surgery – Nasal valve surgery improves airflow in patients with nasal valve compromise. The internal nasal valve, a triangular area between the nasal septum, the lateral nasal wall (specifically, the upper lateral cartilage), and the front of the inferior turbinate (figure 1), is a critically important area of the nasal airway [23], as it has the greatest airflow resistance of the entire upper airway [65]. Nasal valve compromise is frequently due to a septal deformity or turbinate hypertrophy, and correcting these abnormalities often fixes the compromise. In some patients, however, weak upper lateral cartilage allows persistent valve collapse. In severe cases, the alar rim (also called the external nasal valve) may also collapse. These problems are corrected in a variety of ways (table 4). Nasal valve collapse can be less problematic with CPAP if the positive pressure stabilizes the valve, such as when a nasal pillow CPAP interface is used. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Choosing the correct patient-device interface'.)
●Rhinoplasty – A functional rhinoplasty can correct other anatomic nasal airway deformities that compromise airflow, such as traumatic deformities, narrow bony aperture, or abnormally small nares.
●Endoscopic procedures – Concha bullosae (enlarged middle turbinates with an indwelling sinus cell) and nasal polyposis are corrected with endoscopic nasal procedures.
Efficacy of nasal procedures — Nasal surgery as a stand-alone procedure does not reliably treat OSA [66]. Evidence of the benefit of nasal surgery as an adjunctive procedure consists primarily of observational series.
A systematic review of the effect of isolated nasal surgery on CPAP device use and therapeutic pressures identified 18 studies in 279 patients [15]. In seven studies (82 patients) that reported baseline and postoperative device pressure settings, nasal surgery reduced mean CPAP therapeutic pressure from 12 to 10 centimeters of water pressure. Clinical outcomes were variably reported; in a subgroup analysis of 11 studies that included self-reported data on CPAP use, 89 percent of 64 patients who were not using CPAP before surgery were subsequently able to accept, adhere to, or tolerate CPAP after surgery.
In a randomized pilot study, 22 patients with turbinate hypertrophy and difficulty tolerating CPAP were randomly assigned to radiofrequency turbinate reduction or sham control [13]. Compared with the control group, patients who underwent turbinate reduction had significantly improved self-reported CPAP adherence and a trend towards improved objective CPAP use (between-group difference of 32 minutes per night).
Adverse effects of nasal procedures — The most common adverse outcomes following most intranasal procedures include temporary bleeding and temporary nasal congestion. Residual nasal compromise is also a risk.
Other adverse effects vary according to the procedure. Rare adverse outcomes of septoplasty include hematoma, abscess, smell loss, perforation, and saddle-nose deformity. Adverse outcomes of turbinate reduction include intranasal crusting and tissue sloughing, particularly with aggressive turbinate cautery.
Complete turbinate excision is not recommended because it can cause atrophic rhinitis or "empty nose syndrome."
Upper pharyngeal procedures — The primary goal of upper pharyngeal procedures in the context of OSA is to relieve upper pharyngeal obstruction. These procedures should not be used in the absence of suspected upper pharyngeal pathology. If other obstructing areas are present (eg, lower pharyngeal obstruction), additional treatment is required (eg, lower pharyngeal procedures, oral appliance, CPAP, or positional therapy).
Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure for OSA, based on the fact that upper pharyngeal obstruction is the most common anatomic airway abnormality [26-29]. UPPP is a surgical reconstructive procedure that involves reducing, tightening, and/or repositioning the soft palate and related oropharyngeal structures with the goal of improving the airway while asleep. It often includes reduction, removal, or reconfiguration of the uvula.
There are many variations of this procedure (table 5), each focused on correcting pharyngeal airway compromise. Some of the variants may be combined to address complicated palatal obstruction. Usually a palatine tonsillectomy is performed simultaneously if the tonsils are still present.
While excision of palatal tissue was commonly performed for UPPP in the past [28], newer approaches include less resection and more reconstructive principles [24,25,51,67-74]. Selection of the optimal UPPP variant depends on individual anatomy and functional examination of the upper pharynx and palate.
There are numerous classification systems for upper pharyngeal or palatal anatomy that can help predict outcome and/or guide treatment [28,75]. The Friedman classification is commonly cited and stratifies patients by tonsil size, relationship between the oral tongue and soft palate (figure 2), and body mass index (BMI) [59]. Using this classification, large tonsils, a small tongue, and BMI ≤40 predict optimal success. However, utility is limited by the fact that most patients fall into an unclear prognostic classification (ie, Friedman tongue position IIb or III), and it does not guide procedure selection. A newer system classifies more nuanced palatal and pharyngeal configurations and is intended to direct surgical approaches [76].
The other common upper pharyngeal procedures are tonsillectomy and adenoidectomy.
●Tonsillectomy is part of UPPP when the palate procedure is performed simultaneously. Isolated tonsillectomy is reserved for those patients with isolated palatine tonsillar hypertrophy without palatal abnormalities (see 'Tonsillectomy' below). Often a "normal" palate retrodisplaces and obstructs the velopharynx after removal of severely enlarged tonsils because the tonsils were propping the palate anteriorly prior to their removal. In this case, the tonsillectomy may need to be converted to a UPPP to reverse this problem.
●Adenoidectomy can be performed with tonsillectomy or in isolation. Caution is recommended in performing it with UPPP because of the increased risk of circumferential velopharyngeal scar formation and nasopharyngeal stenosis.
Laser-assisted uvulopalatoplasty has fallen out of favor because it does not treat OSA as well as the other surgical techniques, and it poses a risk of abnormal palatal scarring and oropharyngeal stenosis [77,78]. A variety of palatal stiffening techniques have been studied (eg, radiofrequency palatal stiffening, injection sclerotherapy, and palatal implants), but they have minimal effect on OSA [51,79]. (See "Snoring in adults", section on 'Palatal surgeries'.)
Efficacy of upper pharyngeal procedures
UPPP and variants — UPPP and its variants are the most commonly performed surgeries for OSA. Well-controlled studies have shown clinical and polysomnographic benefits but complete elimination of OSA is rare.
●Polysomnography outcomes – The overall success rate of UPPP is approximately 50 percent, with success typically defined as ≥50 percent reduction in the apnea-hypopnea index (AHI) and a postsurgery AHI <20 events per hour [80]. In individual prospective studies, success rates range from approximately 30 to 80 percent. A meta-analysis of two randomized controlled trials reported that UPPP, with or without tonsillectomy, reduced the AHI (mean difference 19) compared with no treatment [81]. Another randomized clinical trial (SAMS) in patients with moderate or severe OSA who had failed OSA devices (eg, CPAP or mandibular advance devices) reported that UPPP combined with minimally invasive tongue volume reduction (using radiofrequency) reduced AHI at six months (mean difference 18) compared with ongoing medical management (eg, ongoing attempts at CPAP, sleep position, weight loss, sleep hygiene) [82]. Also improved were the apnea index, 3 and 4 percent oxygen desaturation index, total sleep time spent with oxygen desaturation <90 percent, and arousal index. However, some long-term studies have shown that the residual OSA may progress partly over time in some patients, even if UPPP is combined with lower pharyngeal surgery [81,83-85]. A limitation of existing data, particularly in older studies, is that both patient selection and specific procedural techniques are highly variable. An early pooled data analysis of observational studies on UPPP found that among all-comers, 41 percent of patients achieved polysomnographic success [28]. Among patients with known palatal obstruction alone (for whom UPPP alone is indicated), however, 83 percent of patients had ≥50 percent reduction in the apnea index. Subsequent studies, including several randomized trials, have shown more favorable improvements in polysomnographic parameters, especially with newer UPPP variants [24,25,69,72,86].
●Snoring – Snoring, which is often the presenting complaint of patients and bed partners, is reduced in the large majority of patients who undergo UPPP [82,87-90]. However, snoring can recur after UPPP; approximately 50 percent of patients maintain a long-term reduction in snoring [87]. Recurrent snoring can be re-treated successfully with minimally invasive palatal stiffening techniques [88,89].
●Daytime sleepiness – Daytime sleepiness and other symptoms, while less consistently reported than polysomnographic outcomes, are frequently improved with isolated UPPP [81,91-94] or a combination of upper and lower pharyngeal procedures [82,93-97]. A meta-analysis of two randomized controlled trials reported that UPPP, with or without tonsillectomy, reduced the Epworth Sleepiness Scale compared with no treatment (mean difference 5.4) [81]. Another randomized clinical trial (SAMS) reported that UPPP plus minimally invasive tongue volume reduction reduced the Epworth Sleepiness Scale compared with ongoing medical management (eg, ongoing attempts at CPAP, sleep position, weight loss, sleep hygiene) in patients with moderate or severe OSA who had failed OSA devices (eg, CPAP or mandibular advance devices; mean difference 6.7) [82].
●Quality of life – Randomized clinical trials as well as other studies have also shown improved quality of life scores postoperatively with varying lengths of follow-up [82,91-93,95-98]. In most of these studies, the magnitude of the improvement in quality of life scores has been in a range considered to be a large, clinically important effect.
●Function and performance – The few well-controlled studies that have tested the effect of UPPP on function and performance indicate that UPPP and variants may reduce motor vehicle crashes and improve reaction time, including in the long term [96,97,99,100].
●Cardiovascular outcomes and mortality – Several large observational studies have suggested that patients who undergo UPPP for OSA have a reduced risk of incident cardiovascular disease and mortality compared with patients with untreated or ineffectively treated OSA, even after adjusting for OSA severity, comorbidities and/or other variables [53-56,101,102]. A mortality benefit has not yet been assessed in randomized trials.
Tonsillectomy — Selected patients with enlarged tonsils and otherwise favorable anatomy (eg, small tongue) may experience cure with simple tonsillectomy, at least with short-term follow-up [103,104]. In a systematic review of case series of tonsillectomy in a total of 216 adults, the mean AHI improved by 65 percent postoperatively (41 to 17 per hour); among 54 patients with sufficient data, 85 percent achieved an AHI <20 events per hour and ≥50 percent reduction, and 57 percent experienced normalization of the AHI (<5 events per hour) [104].
Even if not cured, selected patients who undergo tonsillectomy often experience significant reduction in the high CPAP pressure that was required to splint the airway adequately around noncompliant tonsillar tissue [11,16]. Tonsillectomy in such patients may also lead to a better experience with oral appliance therapy, which does not address tonsillar obstruction itself.
Adverse effects of upper pharyngeal procedures — The most common adverse effects of UPPP are severe transient throat pain in nearly all patients [105] and chronic subjective dysphagia in up to one-third of patients [105,106]. Symptomatic dysphagia may include coughing at meals, nasal regurgitation/velopharyngeal incompetence, food sticking, and/or a globus sensation [95,106].
Several studies have attempted to assess the long-term impact of chronic dysphagia. In one retrospective case series of excisional UPPP, 20 out of 76 patients (29 percent) reported persistent dysphagia one or more years after UPPP [106]. Among 17 patients with chronic dysphagia who were interviewed, 5 reported the need for strict concentration during swallowing at meals to avoid aspiration and 3 regretted having had the procedure; the remaining 14 patients reported that the positive result of the operation outweighed the dysphagia. In another study of excisional UPPP, 22 out of 61 (36 percent) reported persistent dysphagia symptoms five to eight years after surgery, but only one patient regretted UPPP because of dysphagia and lack of snoring improvement [107].
Early postoperative bleeding requiring further care can occur for about two weeks in up to 5 percent of patients [105]. Serious perioperative complications are rare and include airway/respiratory crisis (1.1 percent), cardiovascular events (0.3 percent), major hemorrhage (0.3 percent), or death (0.2 percent) [90,108]. Other potential adverse outcomes include subtle voice change, taste change, compromise of tongue nerves (numbness, pain, or weakness), pharyngeal stenosis (rare), and wound dehiscence [105]. Most of these resolve gradually over months.
The risk of adverse outcomes varies by technique and aggressiveness of the procedure [105]. Newer UPPP techniques that include less resection and more reconstructive principles are associated with fewer side effects and a lower rate of long-term complications [24,25,51,67-73,90]. Likewise, resection techniques can promote oral air leak and decreased CPAP tolerance if CPAP is still needed after surgery [109], whereas the newer reconstructive techniques are associated with improved CPAP tolerance and use [11,110].
Lower pharyngeal and laryngeal procedures — The primary goal of lower pharyngeal and laryngeal procedures in the context of OSA is to relieve a variety of types of obstruction or collapse in these areas. They should not be used in the absence of suspected lower pharyngeal or laryngeal pathology. These procedures are typically used in conjunction with surgery to relieve upper pharyngeal obstruction.
There are several procedures for improving the lower pharyngeal airway, each aimed at a specific target area or problem (table 6). Some procedures occur in the lower pharyngeal airway (eg, midline glossectomy) and others occur at adjacent sites with effects on the lower pharyngeal airway (eg, genioglossus advancement).
Tongue reduction procedures improve the lower pharyngeal airway by decreasing tongue tissue volume. The midline glossectomy creates a trench [111], and the lingualplasty extends the resection laterally [112]. These procedures can reduce tongue volume considerably to reduce retrolingual obstruction. The resultant scar in the tongue base also likely reduces the collapsibility of the tongue base.
In the past, tongue reduction procedures were performed with lasers or electrocautery. With the newer irrigating, suctioning bipolar instruments, bleeding and collateral tissue damage are minimized. Transoral robotic surgery for tongue reduction relies on electrocautery and adds time and cost; however, it provides superior visualization of the surgical field and wristed instruments to allow fine movements.
Radiofrequency tongue reduction is a minimally invasive procedure. It creates a submucosal scar that stiffens the tissue and reduces tongue volume by a mean of 17 percent after five treatment sessions [113].
Lingual tonsillectomy improves the airway by removing obstructing lingual tonsil tissue identified on indirect mirror exam or flexible laryngoscopy (see 'Surgical evaluation' above). Similar to midline glossectomy, the newer irrigating, suctioning bipolar instruments minimize bleeding and collateral tissue injury [114].
Several procedures advance or stabilize the tongue base and pharyngeal musculature. These procedures may be used individually or in combination, depending on the location and severity of tongue base obstruction [115].
●Genioglossus advancement involves creating an osteotomy around the genial tubercle on the anterior mandible and advancing it 10 to 15 mm forward without moving the teeth [116].
●Hyoid suspension advances and stabilizes the hyoid bone to the thyroid cartilage or to the mandible [117]. The hyoid bone is attached to the base of tongue and other pharyngeal musculature (eg, constrictor muscles); therefore, stabilization of the hyoid bone can help stabilize the lower tongue base and pharynx.
●Tongue suspension anchors a suture or tether to the anterior mandible, creating a tongue base sling.
●Mandibular advancement moves forward most of the anterior mandible, including the genial tubercle, other sites of tongue attachment, and the lower teeth.
Epiglottis procedures improve the airway by treating epiglottis collapse and obstruction [30]. Partial epiglottidectomy shortens the epiglottis to prevent critical collapse. Swallowing function is typically preserved as long as residual epiglottis and vallecula remain. Epiglottopexy stabilizes the base of the epiglottis to the tongue base to prevent retroflexion or collapse. Hyoid suspension stabilizes the epiglottis indirectly through its attachment to the hyoid bone via the hyoepiglottic ligament. Some of these epiglottis procedures require a neck incision.
Efficacy of lower pharyngeal and laryngeal procedures — A growing number of studies indicate that in selected patients, lower pharyngeal and laryngeal procedures improve polysomnographic outcomes [28,60,118] and clinical symptoms [60,95]. In a systematic review on multilevel procedures for OSA that included 36 studies, most of which were case series, successful polysomnographic outcomes were reported in 35 to 65 percent of patients [118].
A separate meta-analysis on tongue reduction procedures included 18 studies (mostly case series) and 522 patients [60]. Polysomnographic success was achieved in 60 percent and symptoms of snoring and daytime sleepiness were consistently improved. Most of the studies combined tongue reduction with upper pharyngeal procedures. In the smaller subset of patients with isolated tongue reduction procedures, results appear similar [60,119].
In a systematic review of seven small case series (n = 4 to 27) of direct epiglottidectomy or epiglottopexy (some combined with tongue reduction and/or UPPP), six series showed polysomnographic success (>50 percent reduction in AHI) in 50 percent or more patients [30]. Other polysomnography parameters improved in all series. Other clinical outcomes were not reported.
Long-term follow-up data are more limited. One single-center study identified 77 consecutive CPAP-failure patients who were treated with a staged surgical protocol that included upper pharyngeal, lower pharyngeal, and laryngeal procedures and compared them with 89 simultaneous CPAP-accepting patients who did not undergo surgery [95]. Daytime sleepiness, snoring, quality of life, and adverse events were assessed via mailed questionnaires completed at a mean of 3.7 years after surgery or initiation of CPAP. Both groups experienced improved snoring and sleepiness over time and comparable quality of life outcomes, and each reported frequent but nonserious side effects. The surgery patients also had significantly improved AHI (from 44 to 22 per hour), apnea index (from 15 to 6), and other polysomnography parameters measured at a mean of 20 months after completion of surgery.
Compared with surgical excision techniques, minimally invasive radiofrequency reduction procedures offer simpler recovery but are generally less effective. A randomized, placebo-controlled trial of radiofrequency tongue and palate reduction demonstrated an improvement in the primary outcome of sleep-related quality of life using validated instruments, and a statistical trend of improvement in reaction times, compared with sham radiofrequency ablation [96]. In contrast, the AHI did not improve significantly compared with baseline (mean decrease of 5 from a baseline of 21 per hour), although the apnea index did, possibly suggesting a physiologic shift of apneas to hypopneas. In a long-term follow-up study, the benefits persisted for at least two years [97].
Adverse effects of lower pharyngeal and laryngeal procedures — Adverse outcomes of tongue resection (midline glossectomy or lingualplasty) and lingual tonsillectomy include pain, hemorrhage, inadequate excision, tongue infection, airway complications, prolonged recovery, taste change, dysphagia, and tongue paresis [60,111,112]. The morbidity associated with these procedures has limited their use in the past, but newer surgical instruments (suctioning, irrigating bipolar instruments) greatly reduce these adverse outcomes [60,114].
Minor adverse outcomes of radiofrequency tongue reduction include temporary tongue swelling, dysphagia, and pain. These side effects are mild at one week and completely resolved by three weeks [96]. Rare complications include palatal mucosal breakdown, transient neuralgias, tongue base abscess formation, and airway compromise due to edema [120-123].
Common adverse outcomes of genioglossus advancement include transient tongue swelling and permanent mandibular incisor teeth anesthesia or hypesthesia. Rare complications include lip anesthesia, mandibular tooth root injury, missing the genial tubercle resulting in no genioglossus advancement, wound dehiscence, infection, change in chin profile, or pathological mandible fracture.
Adverse outcomes of hyoid suspension are rare and include prolonged dysphagia, infection, rupture of hyoid suspension suture (more common when suspended from the mandible, rare when suspended from the thyroid cartilage), or voice change.
Adverse outcomes of tongue suspension suture commonly include improper position, pain, swelling, and inflammation of the sublingual salivary glands; uncommon complications include suture rupture, foreign body reaction, tongue paresis, hemorrhage, or infection.
The main risk of epiglottidectomy is laryngeal penetration or aspiration if excision is too aggressive or if abnormal scarring occurs. Likewise, epiglottopexy has the same risk if abnormal scar tethers the tip of the epiglottis to the tongue, and it also risks dehiscence with inadequate stabilization. These and other complications (bleeding, taste changes) are uncommon [30].
Global upper airway procedures — Global upper airway procedures include three diverse procedures, each with specific indications that can improve the upper and lower pharyngeal airway globally or bypass the upper airway; they are not site-directed (table 7).
●Maxillomandibular advancement – Maxillomandibular advancement projects the entire lower facial skeleton and attached soft tissues forward. The upper and lower teeth are moved with the jaw bones either in native occlusion or moved differentially to correct an anterior-posterior malocclusion. Occlusion correction requires concomitant pre- and postoperative orthodontics. This procedure stabilizes and improves the caliber of the upper and lower pharyngeal airway [36]. It also tightens the lateral pharyngeal walls by placing soft tissues under tension [124].
●Tracheotomy – Tracheotomy bypasses the entire upper airway and can eliminate or dramatically reduce OSA [28]. An OSA tracheotomy cannula is usually used instead of a standard tracheotomy tube. The cannula is smaller, more comfortable, and easier to manage than a standard tracheotomy tube. Patients can eat and speak normally with the cannula capped during waking hours and can breathe easily with the cannula open during sleeping hours [125]. The tracheotomy requires vigilant maintenance to minimize complications, such as cannula occlusion, mucus plugging, bronchitis, pneumonia, stomal granulation tissue formation, and peristomal infections. For severely obese patients, a skin-lined tracheotomy helps control stomal granulation and peristomal infections [126].
●Upper airway stimulation (eg, hypoglossal nerve stimulation) – Upper airway stimulation via an implantable neurostimulator device (picture 1) activates the protrusion muscles of the tongue via the hypoglossal nerve to open the lower pharyngeal airway. It also improves the upper pharyngeal airway by physiological and anatomical coupling of the tongue to the palate, as long as the upper pharynx does not have a concentric collapse pattern [19,57,127-130]. Thus, stimulation has a combined upper and lower pharyngeal airway effect in properly selected patients.
Current US Food and Drug Administration (FDA) eligibility criteria for upper airway stimulator implantation include age ≥22 years, moderate or severe OSA (defined as AHI 20 to 65 events/hour), predominantly obstructive events (defined as central and mixed apneas ≤25 percent of AHI), CPAP failure (defined as AHI >20 on CPAP) or intolerance (defined as use <4 hours per night, five nights per week; or unwillingness to use), no complete concentric velopharyngeal collapse on screening sleep endoscopy, and no other anatomical findings that would compromise performance of the device (eg, tonsil size 3 or 4) [21,22,57]. It is not recommended for patients with BMI >32 kg/m2 [22,57,127,131].
Efficacy of global upper airway procedures — Among the various types of surgical procedures, maxillomandibular advancement and tracheotomy are generally associated with the greatest degree of improvement in polysomnographic parameters of OSA. However, maxillomandibular advancement is a major operation that is typically reserved for patients with persistent, significant OSA following other site-directed surgical treatments [132] or with baseline maxillary or mandibular hypoplasia. Most patients wish to avoid tracheotomy, so it is typically reserved for patients with severe OSA who fail CPAP therapy and who cannot tolerate upper airway reconstruction because of critical comorbidities.
In a meta-analysis that included 21 unique cohorts of patients (n = 627) undergoing maxillomandibular advancement, the overall success rate (defined as an AHI <20 events per hour and reduced by at least 50 percent) was 86 percent [58]. Cure of OSA (defined as an AHI <5 events per hour) was achieved in 43 percent of patients. Lower baseline BMI and greater maxillary advancement were the only independent predictors of success or cure. Prior UPPP was associated with more severe OSA and higher BMI, but it was not independently associated with success or cure (or worse outcome). Long-term follow-up data are more limited, but in one small study 36 out of 40 patients had persistent improvement in polysomnographic parameters at a median of four years after surgery [133].
Maxillomandibular advancement has also been associated with improved reaction time, snoring, sleepiness, quality of life, and other subjective measures, although these outcomes are less consistently reported [58,134-137].
Tracheotomy offers the most immediate and definitive surgical success. In a meta-analysis of 18 studies, most of which were retrospective case series, the mean obstructive apnea index decreased from 73 to <1 post-tracheotomy, but effects on the AHI and oxygen desaturation indices were less complete [138]. In a second meta-analysis of morbidly obese patients undergoing tracheotomy, oxygenation parameters often remained severely abnormal [139], possibly due to obesity hypoventilation syndrome, excessive dynamic airway collapse [140], or tracheotomy compromise.
More limited data indicate that tracheotomy improves daytime sleepiness [138], even in morbidly obese patients [139]. In one study, tracheotomy was associated with reduced cardiovascular mortality when compared with untreated historical cohorts [138].
Upper airway stimulation therapy (eg, hypoglossal nerve stimulation) via a surgically implanted device is a promising treatment for OSA in selected patients [57,127,141-145]. A meta-analysis of uncontrolled studies of upper airway stimulation therapy showed 50 to 57 percent reductions in AHI, 48 to 52 percent reductions in oxygen desaturation index, and significant improvements in sleepiness and quality of life at 3 to 12 months [127]. In another meta-analysis of 350 patients from 12 uncontrolled studies of three different devices in non-obese patients at 12 months, AHI reduction ranged from 18 to 24 and Epworth sleepiness scale improvement ranged from 2.9 to 5.3 [144].The largest individual study of 126 highly selected patients showed major improvements in polysomnography parameters in about two-thirds of patients, improvement in subjective measures of sleepiness, and high adherence (84 percent) [57]. These benefits were maintained at five years postoperatively [141]. One long term study also reported no significant change in the intensity of stimulation over a period of four years [146].
This therapy is continuing to evolve with ongoing enhancements in the device hardware, software, implantation procedure, and treatment protocols. One device is commercially available in the United States, and others are in various stages of testing.
Adverse effects of global upper airway procedures — Adverse outcomes of maxillomandibular advancement include facial and dental anesthesia/paresthesia, hemorrhage, malocclusion, trismus, unfavorable cosmesis, malunion, nonunion, hardware extrusion, infection, skeletal relapse, or velopharyngeal incompetence. Depression can occur because of the prolonged duration of sensory changes of the lips, the associated drooling, and limited ability to eat regular food for months. Common permanent side effects include minor dental or facial anesthesia/hypesthesia and minor occlusal changes.
Adverse outcomes of tracheotomy commonly include stomal granulation tissue, peristomal cellulitis, tracheitis/bronchitis, stomal scar tissue, and cannula dislodgement [28]. In one series, 42 percent of patients developed granulation tissue at the tracheotomy stoma [147]. Less common complications include stomal bleeding, thyroid hemorrhage, aspiration, tracheal erosion, or tracheoinnominate fistula. Use of an OSA tracheotomy cannula improves patient tolerance and reduces the risk of complications compared with a regular tracheotomy tube [125]. Tracheotomy patients tend to have severe comorbid conditions, which may increase the risk of perioperative complications.
Adverse outcomes of upper airway stimulation include device failure, infection, need for explant (5 percent), tongue weakness, and tongue irritation (from movement against the teeth) [57,127]. No additional risks were identified after five years in one cohort [141], with serious device-related adverse events in 6 percent of patients at five years. It is not yet known whether there are longer-term risks, such as decayed effect (due to fibrosis between stimulating lead and hypoglossal nerve, for example), tongue hypertrophy, hypoglossal weakness, or device breakdown. In a retrospective review of the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, 134 adverse events were identified over a five-year period [148]. Device revision was required in 32 cases and device explantation in 17 cases. Common adverse events were device migration and infection. Rare events not seen in clinical trials included pneumothorax, pleural effusion, and lead migration into the pleural space.
FOLLOW-UP AND MONITORING — Patients who undergo surgery for obstructive sleep apnea (OSA) should receive both surgical and medical follow-up. The frequency of surgical follow-up is determined by the type of surgery, but should include assessment of wound healing, the anatomical result, side effects, complications, and need for further staged surgery.
Once recovery is complete and a new steady-state sleep pattern has been established, polysomnography or home sleep apnea testing should be performed to determine the degree of residual OSA [1,90]. Typically four months is sufficient for healing to take place, but it depends on the extent of surgery. (See "Overview of polysomnography in adults", section on 'Indications' and "Home sleep apnea testing for obstructive sleep apnea in adults".)
Reassessment is generally coordinated by a sleep specialist. Long-term follow-up by the sleep specialist is indicated to monitor for residual or recurrent OSA, and to coordinate adjunctive use of continuous positive airway pressure (CPAP) or other therapies.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sleep-related breathing disorders in adults".)
SUMMARY AND RECOMMENDATIONS
●Surgery can play an important role in the management of obstructive sleep apnea (OSA) as secondary therapy for selected patients who fail or do not tolerate positive airway pressure (PAP) therapy and as adjunctive therapy. (See 'Roles of surgery' above.)
●Surgical candidacy depends on three main factors: patient desire, the existence of a surgically correctable problem, and fitness to undergo surgery. (See 'Patient selection' above.)
●Upper airway surgery in patients with OSA should be performed in conjunction with a comprehensive preoperative assessment and follow-up plan. The clinical assessment includes review of polysomnographic data and symptom burden to determine OSA disease severity, an assessment of the patient's past experience with treatment modalities such as continuous positive airway pressure (CPAP) therapy or an oral appliance, and evaluation of comorbidities. (See 'History' above.)
●A thorough upper airway examination provides the anatomical basis of surgical decision-making. In addition to the clinical examination of the head and neck, transnasal flexible laryngoscopy is often indicated to examine the full pharyngeal airway with the tongue in its native position. Drug-induced sleep endoscopy and craniofacial and upper airway imaging are additional tools used in selected patients. (See 'Physical examination' above and 'Laryngoscopy' above and 'Craniofacial and upper airway imaging' above.)
●Procedure selection takes into account multiple factors related to a patient's anatomy, including native anatomy and anatomic abnormalities, the presence and pattern of dynamic collapse, and preservation of physiologic functions. Many surgeons take a site-directed, staged approach to surgical therapy. (See 'Procedure selection' above.)
●Surgical treatment for OSA provides long-term benefits in selected patients, although complete elimination of OSA is often not achieved, depending on the specific procedure. Predictors of benefit are inconsistent across studies but generally include lower body mass index (BMI) and less complicated obstruction. (See 'Surgical outcomes' above.)
●Nasal surgery as a single intervention does not reliably treat OSA. The primary goal of nasal procedures in the context of OSA is to improve CPAP, oral appliance, or other surgery effectiveness in selected patients affected by nasal obstruction. Nasal surgery can improve CPAP tolerance, reduce CPAP pressure requirements, or complement oral appliance and other surgical therapies. Examples of nasal procedures used for this purpose include turbinate reduction, septoplasty, and nasal valve surgery. (See 'Nasal procedures' above.)
●Uvulopalatopharyngoplasty (UPPP) and UPPP variants are the most common surgical procedures for OSA, based on the fact that upper pharyngeal obstruction is the most common anatomic airway abnormality. UPPP frequently improves both the physiologic abnormality of OSA and clinical symptoms, but the degree of polysomnographic benefit as evidenced by the apnea-hypopnea index (AHI) is variable, and cures are rare. Important adverse effects include chronic mild dysphagia in up to one-third of patients. Simple tonsillectomy in selected patients with tonsillar hypertrophy and otherwise favorable anatomy (eg, small tongue) is associated with a high rate of success. (See 'Upper pharyngeal procedures' above.)
●Lower pharyngeal and laryngeal procedures aim to improve the retrolingual and/or laryngeal airway. Some procedures occur in the lower pharyngeal airway (eg, midline glossectomy, epiglottidectomy), some occur at adjacent sites with effects on the lower pharyngeal airway (eg, genioglossus advancement), and others aim to reduce, advance, or stabilize the tongue base. (See 'Lower pharyngeal and laryngeal procedures' above.)
●Global upper airway procedures improve multiple levels of airway obstruction. Maxillomandibular advancement is generally associated with a large degree of improvement in polysomnographic parameters of OSA. However, it is a major procedure that is typically reserved for patients with persistent, significant OSA following other site-directed surgical treatments or with baseline maxillary or mandibular hypoplasia. Tracheotomy is usually reserved for patients with severe OSA who fail CPAP therapy and who have critical comorbidities. Upper airway stimulation via an implantable neurostimulator is promising treatment of the upper and lower pharyngeal airway in selected patients. (See 'Global upper airway procedures' above.)
●Since surgical treatment of OSA is typically an incomplete therapy, longitudinal follow-up is important for optimal long-term outcomes. The clinical and physiologic efficacy of the surgical procedure should be assessed postoperatively by history and polysomnography or home sleep apnea testing. (See 'Follow-up and monitoring' above.)
