Obstructive sleep apnea (OSA) affects an estimated 2 to 4 percent of adults and is associated with multiple morbidities, including hypertension, congestive heart failure, myocardial infarction, diabetes and neurocognitive impairment. In addition to these significant health consequences, the effects of OSA can extend to an increased risk for motor vehicle accidents and an impaired quality of life (BMJ. 2008;336:44-45; Laryngoscope. 2012;122:1878-1881; Sleep. 2007;30:461-467).
Explore this issue:February 2013
Identifying and treating patients with this disorder is imperative, but how do we determine that we have, in fact, successfully improved the health of individuals for whom surgical intervention was deemed necessary?
Once a diagnosis of OSA is made, most patients receive the front line of OSA treatment: continuous positive airway pressure (CPAP) devices. In most cases, sleep quality is improved quickly, and daytime sleepiness is reduced. But CPAP use has a number of side effects. The mask can cause a claustrophobic feeling, and the airflow can result in a dry, sore mouth and nasal congestion. These discomforts are significant enough for many patients to stop using the device. Patient compliance is a major obstacle to successful CPAP therapy, which is defined as reducing the apnea-hypopnea index (AHI) to 5 or less, effectively “normalizing” the patient’s breathing during sleep.
Should CPAP therapy fail, either through lack of compliance or simple lack of effectiveness, surgery may be indicated. Surgery is a second-line OSA treatment, used strictly when CPAP or mandibular advancement devices have not delivered relief. In some cases, surgery can be considered as a first-line treatment if the patient exhibits an obvious anatomical abnormality that could be blocking airflow to the lungs. In these cases, correcting the anomaly could successfully eliminate the problem.
Surgical interventions for OSA depend on the anatomical issue being addressed. Procedures include:
- Maxillo-mandibular advancement (MMA): skeletal surgery that advances the soft palate, tongue base and suprahyoid musculature and stabilizes the alterations with screws, plates or bone grafts;
- Uvulopalatopharyngoplasty (UPPP): excision of the tonsils and posterior soft palate and closure of tonsillar pillars;
- Modified UPPP: additional mucosa and submucosal adipose tissue are removed superior and lateral to the tonsillar fossa and from the posterior soft palate;
- Laser assisted UPPP: outpatient procedure using laser incisions to shorten uvula and tighten soft palatal tissues; and
- Soft palatal implants: a less invasive procedure in which Dacron rods are inserted into the soft palate under local anesthesia (Sleep. 2010;33:1396-1407).
Complexities of AHI
Determining OSA surgical success is complex at best. Many physicians believe that the efficacy of the procedure is best evaluated by monitoring the patient after surgery overnight in a sleep lab. This method yields hard data: The post-procedure AHI can be compared side by side with the person’s baseline. The challenge here again is patient compliance. While some patients are eager to discover just how much their condition has objectively improved, many physicians find it difficult to convince patients to spend another night in the sleep lab. Patients who feel significantly better may be particularly eager to put the whole OSA experience behind them. In addition, not all insurance providers are willing to reimburse a procedure they consider a mere exercise.