Things to discuss when considering surgery for snoring and sleep apnoea

Things to discuss when considering surgery for snoring and sleep apnoea

Snorer.com
Rated 5/5 based on 1 customer reviews
Author: Adrian Zacher MBA.

Peer reviewed by: Professor Bhik Kotecha FRCS ↗ and Professor Iain Ormiston FRCS

Last review: 14 November 2017 Next review: November 2019

Snoring and obstructive sleep apnoea may be thought of as essentially the same problem but at different levels of severity. Snoring may be defined as “breathing during sleep with hoarse or harsh sounds”, while obstructive sleep apnoea (OSA) is not just noisy, it is when the airway during sleep collapses, causing obstruction, and the obstruction causes the apnoea (cessation of breathing).

Although surgeries are rarely performed, surgical approaches have been largely confined to reduction of the soft palate and uvula (dangly bit in the mouth) and/or removal of nasal polyps (‘lumps’ inside your nasal airway) or septum straightening (correcting a crooked nose) and more recently advancing the upper and lower jaws which advances the soft palate and tongue, opening up the airway, known as an MMA.

If you are considering surgery, your hospital doctor or specialist will discuss the options with you. This will include the likelihood of success, goals of the treatment, risks and benefits of the procedure, possible side-effects, complications and alternative treatments2.

This guide does not pretend to explain everything in detail; it is intended to provide an accessible, evidence-based introduction, sufficient to help you engage in conversation with your medical professional.

NHS England's Information Standard Certified Member

References in the Appendix

There are lots of external references in this Guide. The reference information can be found in the References section of the Appendix at the end of the Guide.

Apnoea or Apnea?

Snorer.com uses the UK spelling of ‘apnoea’ rather than the more widely used US spelling ‘apnea.’
Surgery for snoring presented by Professors
MMA = maxilla and mandible advancement surgery

ACRONYM ALERT!

MMA = Maxilla (upper jaw) Mandible (lower jaw) Advancement

While this is of course general information, in the diagram below (Figure 1) you will see how the various therapies, lifestyle changes and surgery all interrelate. Where you are on the disease severity axis, along with any other conditions you may have, could indicate various options.

Figure 1: Complementary therapies along the spectrum of disease

Figure 1: Complementary therapies along the spectrum of disease
The myriad of variables is one reason why you must have an overnight sleep apnoea assessment (known as a ‘Sleep Study’) and a thorough ENT examination before considering any form of surgery.3 If there is a restriction in your throat, that if removed would help you use another treatment more effectively, then exceptionally, surgery may help.

If you have a ‘set back’ or what is known as a retruded lower jaw (where your teeth are well behind those of the upper jaw) surgery to advance your lower jaw (which will also bring the tongue forwards and open the airway) may be indicated. Even those with normal ‘bite’ positions may benefit from the advancement of the upper and lower jaw.

PAP = Positive Airway Pressure therapy.

ACRONYM ALERT!

PAP = Positive Airway Pressure

(See our “How to choose… Positive Airway Pressure therapy” Guide.) ↗

 

Various acronyms for Mandibular Advancement Device (MAD)

JARGON ALERT!

MRD (Mandibular Repositioning Device), MAS (Mandibular Advancement Splint). Mouthpiece, ‘Gumshield’, Oral Appliance, Device, Splint…
These are different names for the same thing: a device worn in your mouth, which holds your lower jaw forwards, to help you breathe better while asleep.
ENT = Ear Nose and Throat

ACRONYM ALERT!

ENT = Ear Nose and Throat
Retrognathic mandible

JARGON ALERT!

Medical and dental professionals may describe this as a ‘receding’ mandible (lower jaw) or retrognathic.

The extract below is taken from the 2005 “Surgery for Obstructive Sleep Apnoea in Adults”, Cochrane Database of Systematic Reviews. 4

The Cochrane database has an excellent reputation, as they collate medical papers and review lots of patients with similar problems.

“Surgery for obstructive sleep apnoea / hypopnoea syndrome aims to relieve obstruction by increasing the size of the airway in the throat, bypassing the airway or removing a lesion. A limited number of trials assessing diverse surgical techniques were identified. There were inconsistent effects reported across the trials. The available evidence from these small studies does not currently support the widespread use of surgery in people with mild to moderate daytime sleepiness associated with sleep apnoea.”
Further information can be found in the References section of the Appendix at the end of this Snorer.com Guide.
Cochrane report surgery for obstructive sleep apnoea
This means that, as a general rule, surgery is appropriate for snoring but not for sleep apnoea. However, in a select group of patients surgical intervention may be appropriate even in the mild or moderately severe sleep apnoeic person. In other words, Cochrane is unable to prove surgical results. However, since 2006, it has been appreciated that in cases of severe OSA, MMA is appropriate for those that cannot use cPAP.

For example, if the individual had nasal polyps or really enlarged tonsils, then surgical intervention may result in a dramatic improvement in their symptoms. There are a number of patients who cannot tolerate PAP or mouthpieces and are not willing to accept PAP as a lifetime therapy. This selective group, while admittedly small in numbers, may benefit from complex surgery.

Broadly speaking, surgery could be considered either to improve upper airway anatomy in such a way so that it facilitates PAP therapy or preferably to overcome the upper airway obstruction completely and negate the need for PAP therapy.
MMA = maxilla and mandible advancement surgery

ACRONYM ALERT!

MMA = Maxilla & Mandible Advancement (upper and lower jaw).

PAP = Positive Airway Pressure

C = Continuous

Nasal polyps block the nasal airway

JARGON ALERT!

Nasal polyps are explained in more detail on page 11 of this Snorer.com Guide (PDF) or scroll down.

Surgery for snoring and sleep apnoea

This Snorer.com Guide follows the logical flow of air into your body, through your nose, down your throat and past your larynx. Then it moves to surgery on the actual structure of your face – the bones.

In the same way that snoring and OSA are points along a line, the surgical approach changes and becomes progressively more serious from ENT to Oro-maxillofacial surgery, in correlation with the severity of the sleep problem.

History, examination, tests, diagnosis

You will no doubt have heard of the terms ‘diagnosis’ and ‘treatment’. To determine what is happening (diagnosis) and how to help you best (treatment), the surgeon will review your medical history and ask you to undergo various thorough examinations and assessments.

As there are many causes of snoring – no one solution is appropriate. Only after an accurate diagnosis can the right treatment for you be determined.

Before you decide on surgery, talk it over with your GP or specialist Consultant and your partner. Surgical options for OSA are not usually recommended, as sleep apnoea responds better to positive airway pressure therapy (PAP) and can usually be managed through non-surgical means.

In a highly select group of patients however, surgery may be appropriate if treatment with PAP or mouthpieces [oral appliances] has failed.5

Radical surgery, as opposed to minimally invasive surgery, is irreversible. Once you have had surgery to remove something – it is gone. Minimally invasive surgery usually avoids removal of tissue and relies instead on scarring or stiffening floppy tissue.

Figure 2: Overview of the route to treatment.

Assessment, diagnosis, treatment

ASSESSMENT       DIAGNOSIS       TREATMENT

surgery for snoring ASSESSMENT – Together with a review or your history, this is to ask “what is wrong” and includes a review of your signs and symptoms (i.e. what you complain of and what the surgeon detects) together with examination and results of any tests.
surgery for sleep apnoea DIAGNOSIS – The assessment may then facilitate a diagnosis, the underlying cause of your problem.
treatment for sleep apnoea TREATMENT – Finally, provide the best answer to solve your problem, the ‘treatment’. This quite often involves more than one anatomical level – a so-called multi-level problem.

Generally it is appropriate to undertake the simplest and safest procedure to address the diagnosed problem to correct any anatomical obstruction.

Multi-level surgery for snoring

JARGON ALERT!

Multi-level being nose, soft palate and/or tongue. Multi-level upper airway surgery means, surgery upon many areas at the same time, to maximise effect.

Likelihood to gain weight

Your weight is an important confounding factor for sleep apnoea.6 If you lose weight it can have a positive impact and potentially lessen the severity of your sleep apnoea.7

Conversely, if you gain weight it can make your sleep apnoea worse. So, surgery for your current condition has to be considered in the context of your likelihood to change weight.

This is something to think carefully about, discuss with your partner and your surgeon.

If you are overweight and can lose weight, a simple analogy would be that post weight-loss you will be breathing through a larger diameter snorkel.

There is more about weight and sleep apnoea in the Bariatric Surgery section.

Further information can be found in the References section of the Appendix at the end of this Snorer.com Guide.
If you gain weight it can make your sleep apnoea worse

Surgery confined to soft tissue

There is currently some difficulty in identifying who would benefit from surgery. It is not yet clear who will find that surgery resolves their problem and who will find that after a period the symptoms return. 8

Surgery may be required to address the nose, soft palate, tonsils and tongue. In many cases more than one anatomical region may need correction – this is known as multi-level surgery.

Polyps, tonsils, turbinates and deviated septums are abnormalities that compromise the nasal passage and result in patients complaining of nasal congestion. In addition, patients may also have other physiological complaints such as those of allergic rhinitis – the common allergens being pollen, dust mites or animals. Nasal congestion would certainly interfere with PAP therapy compliance and may need medical and surgical attention.

Any form of surgery would only occur after a thorough ENT assessment.

Figure 3 illustrates a nasal polyp (white area in the middle of the image). It is blocking most of the air passage in the nasal cavity. As such, it makes it difficult to breathe through this nostril making the air in the other nostril travel faster vibrating the tissue (making a snoring noise) or perhaps even collapsing the nostril altogether!

Figure 3: View of the nasal cavity showing a polyp.

 

Nasal polyp blocking most of the air passage in the nasal cavity

This diagram represents a view up your nose. The pink area is your skin; the white area is the ‘polyp’ that is causing the problem and the dark area is where air travels as you breathe. The polyp is blocking most of the nasal airway on this side of the nasal cavity.

Surgery is occasionally considered as a first treatment when patients with snoring and/or mild sleep apnoea have severe obstructing anatomy that is surgically correctable. For example, having enlarged tonsils which restrict breathing.9

Surgery may also be considered to improve your ability to use other treatments such as PAP and oral appliances (mouthpieces). 10

Surgeons’ assessments for snoring then focuses upon the soft palate.

Is it creating the snoring noise by ‘flapping’ in the airflow as you breathe? This is where careful assessment can help the surgeon identify the problem. These tests may include passing a camera up your nose while you perform jaw and breathing manoeuvres.

There are several approaches to stopping this ‘flapping’ tissue at the back of your throat – read on!

Palatal surgery may be performed by a minimally invasive approach whereby the soft palate does not change its shape – instead it is tightened using injection Snoreplasty®, palatal pillar implants or by performing radio-frequency surgery. Alternatively, more radical palatal surgery involves shortening and stiffening the soft palate by performing laser assisted uvulopalatoplasty (LAUP) or uvulopalatopharyngoplasty (UPPP).

 

  • Surgical removal or reduction
    • Uvulopalatopharyngoplasty (UPPP)
      Involves removal of the uvula (dangly bit at the back of the throat) and portions of the soft palate
  • Radio-frequency ablation
    • Laser Assisted Uvulopalotoplasty (LAUP)
    • Stiffening. Achieved through a process known as radio-frequency ablation or by implanting a rod into the soft palate.
Surgery confined to soft tissue allergic rhinitis

JARGON ALERT!

Multi-level being nose, soft palate and/or tongue. Multi-level upper airway surgery means, surgery upon many areas at the same time, to maximise effect.

Changes inside your nose, and further back, that restrict your breathing.

Allergic rhinitis often causes cold-like symptoms, such as sneezing, itchiness and a blocked or runny nose.

PAP = Positive Airway Pressure

ACRONYM ALERT!

PAP = Positive Airway Pressure
ENT (Ear Nose and Throat) Surgeons, Otolaryngologists, and Head & Neck Surgeons are three different titles for similar expertise.
Nasal polyp

JARGON ALERT!

A polyp is a particular kind of abnormal tissue growth.

The nasal cavity is the air filled space above and behind your nose. The floor of the nasal cavity forms the roof of your mouth (palate).

Drug induced sedation endoscopy

JARGON ALERT!

This procedure is known as a ‘nasendoscopy’ and is sometimes performed while you are asleep, which is known as – Drug Induced Sedation Endoscopy (see explanation on page 7).
Snoreplasty surgery for snoring

JARGON ALERT!

Snoreplasty® is a procedure that is less invasive than open surgery. Check out the Jargon Buster at https://snorer.com/jargon-buster/

These scary sounding and sometimes unpronounceable terms are explained further (with pictures!) on the next
few pages.

Radio-frequency surgery

A number of procedures are available, and includes Somnoplasty®, Coblation® or Celon® radiofrequency. These are different energy emitting devices that can be used on the soft palate and/or the tongue to reduce the size and amount of soft tissue.

In some cases, these procedures can be carried out under local anaesthesia but more often, if multi-level treatment is required, then general anaesthesia may be more appropriate.

Radio-frequency ablation might be worth considering as an option if you have mild/moderate sleep apnoea, and have tried PAP and a mouthpiece [oral device] without success.11

Figure 4: Radiofrequency ablation surgery.
Radio-frequency ablation for snoring

A small probe is inserted into the area to be reduced. The tissue is internally heated, thus reducing the bulk and stiffening the tissue, which makes it less likely to vibrate as you breathe and create the snoring noise.

Multi-level upper airway surgery for snoring

JARGON ALERT!

Multi-level upper airway surgery means, surgery upon many areas at the same time, to maximise effect.

Radio-frequency ablation is a surgical method of reducing and stiffening soft tissue within the body by a minimally invasive procedure.

In general, radio-frequency ablation does not have serious side-effects and pain is reported to occur for less duration (2.5 days on average) than other procedures.12 It is a sequential procedure that may take 3 or 4 outpatient visits to complete and NICE have suggested that short-term effectiveness and long term outcomes of this procedure are uncertain. 13
NICE= National Institute for Health and Care Excellence

JARGON ALERT!

NICE = National Institute for Health and Care Excellence

Laser Assisted Uvulopalatoplasty (LAUP)

We have mentioned a form of surgery called laser assisted uvulopalatoplasty (LAUP). This procedure also assumes that the snoring noise is created by the soft palate. Many patients do not have an exclusively soft palate problem, adding emphasis to the importance of thorough history, tests and examinations.

Figure 5: Laser assisted uvulopalatoplasty (LAUP)
Laser assisted uvulopalatoplasty (LAUP) for snoring
A laser is used to scar and sometimes remove the tissue and stiffen it, making it less likely to vibrate and make the snoring sound.
LAUP is a sequential procedure that may take 3 or 4 outpatient visits to complete.14 Obstructive sleep apnoea is a serious medical condition. As such, it is a problem for the patient themselves and not so much a partner perceived anti-social snoring problem.

LAUP is not usually recommended in isolation for the treatment of obstructive sleep apnoea15 however, in selected cases, it may be appropriate to perform LAUP in conjunction with other surgical procedures addressing upper airway obstruction.

Soft palate implants

This is a relatively new technique stiffens the soft palate instead of removing it. The idea is that rods known as a ‘pillar implants’ are inserted into the soft palate under a local anaesthetic, to reduce the tendency to vibrate (and make noise).

Figure 6: Soft palate implants

Soft palate implants for snoring
Typically three small nylon rods are inserted completely under the skin to stiffen the soft palate to reduce the tendency to vibrate.
In the USA, the FDA has approved certain soft palate implants in selected patients for snoring and mild to moderate sleep apnoea.

However, in the United Kingdom, NICE guidelines16 state that:

“Current evidence on soft-palate implants for obstructive sleep apnoea (OSA) raises no major safety concerns, but there is inadequate evidence that the procedure is efficacious in the treatment of this potentially serious condition for which other treatments exist. Therefore, soft-palate implants should not be used in the treatment of this condition.”
FDA = Food and Drug Administration and NICE = National Institute for Health and Care Excellence (previously known as National Institute for Clinical Excellence)

ACRONYM ALERT!

FDA = Food & Drug Administration (USA)

NICE = National Institute for Health and Care Excellence (previously known as National Institute for Clinical Excellence)

Although not currently offered by the NHS in the UK, pillar implants are available privately. Factors such as appropriate patient selection and correct placement of the implants are very important for success. In a recent study ~9% of the implants ‘extruded’ which means they came out from under the skin and had to be removed 17.
NHS = National Health Service in the United Kingdom.

JARGON ALERT!

NHS = National Health Service (UK)

UvuloPalatoPharyngoPlasty (UPPP)

An invasive surgical procedure called a uvulopalatopharyngoplasty (UPPP) may, in certain circumstances, be performed. It is less commonly performed than in the past. Patient selection is very important to determine who will obtain a positive response from the surgery 18.

Figure 7: UvuloPalatoPharyngoPlasty (UPPP)

Uvulopalatopharyngoplasty (UPPP) for snoring
This diagram represents a view of the back of the throat.
The uvula (dangly bit in the middle) has been removed along with the tissue on both sides (pharyngeal walls).
While you are under a general anaesthetic, the surgeon trims the tissue at the back of your throat. Reducing the tissue in this area may open up your airway and make it wider. This sometimes can allow air to move through the throat more easily when you breathe, reducing the severity of obstructive sleep apnoea (OSA).
If your snoring is caused by large tonsils and/or adenoids, these can be removed in an operation called a tonsillectomy or adenoidectomy. Your surgeon would discuss this with you as this operation may be performed at the same time as the UPPP.
There are serious risks associated with UPPP surgery, including what is known as nasal incompetence and severe post-surgery bleeding.
'ectomy' means surgical removal of tissue.

JARGON ALERT!

‘Ectomy’ means the surgical removal of tissue- in this case the Tonsils or Adenoids (lymphatic tissue).

Nasal incompetence describes a condition where what you normally swallow comes out of your nose instead.

Trans-oral robotic surgery (TORS)

Trans-oral robotic surgery (TORS) is a new, ‘salvage’ surgical procedure for selected patients with moderate to severe OSA, who have not tolerated or not successfully used other treatments.

When assessment and diagnosis have implicated the base of the tongue as being the cause of the problem, TORS improves access to the tongue base area (compared to conventional ‘line of sight’ approaches) because it enables the surgeon to operate ‘around corners’.

This improvement may correlate with improved surgical outcomes, however, long-term comparative evaluation in larger patient samples is necessary.

Trans-oral robotic surgery for sleep apnoea

JARGON ALERT!

Trans-oral robotic surgery is a futuristic technology that allows surgical removal of soft tissue in tight spaces.

The robot is guided by a surgeon from a command console using 3-D imaging and instruments attached to the robotic arms and even has the capability to work around corners!

Salvage surgery for sleep apnoea when all other options have been unsuccessful

JARGON ALERT!

Salvage in this case meaning it’s a last chance option when other treatments have been unsuccessful.

Oral & Maxillofacial surgery

Oral & maxillofacial surgery is “surgery on the bones of the mouth, jaws, teeth and face.” It is indicated for treatment of severe sleep apnoea in patients who cannot tolerate or have found PAP and mouthpieces ineffective.19 Also, should your jaws not align, surgery can change this, it may be particularly relevant if your lower jaw is set well behind the upper (undershot). Oral & maxillofacial surgery is a useful single procedure able to correct airway obstruction at all levels with increasing evidence of success.20

If you lie on your back with an obstructed airway, the first aid principle is to hold the lower jaw (and tongue) forward – the so-called ‘tongue thrust.’ Mandibular advancement surgery mimics this movement 24 hours a day, 7 days a week.

It is very important to weigh up the likelihood of success, goals of the surgery, possible side-effects, and complications and consider alternative options.21

Oral & maxillofacial surgery, in particular the advancement of both the upper and lower jaw, often known as MMA, is major surgery that will change your appearance, sometimes this may be considered a positive.22

It may be indicated where facial skeletal discrepancies are associated with sleep apnoea (confirmed by a sleep study) and is advocated for selected patients who have failed PAP and mouthpiece (oral appliance) therapy.

This type of surgery may have other unintended consequences; concerns, other than the surgery itself, include a change in your appearance, risk of nerve damage to the lower lip resulting in perhaps permanent loss of sensation (similar to numbness you may experience after a dentist visit) and two variables known as remodelling and relapse.

However, in general, MMA shows that the mild changes to facial profile / appearance are commonly an improvement. Those with severe obstructive sleep apnoea will usually have obstructions at multiple levels: nose, palate and base of the tongue. Advancement of the upper and lower jaw corrects obstructions at all levels.

PAP = positive airway pressure therapy for sleep apnoea

JARGON ALERT!

PAP = Positive Airway Pressure
Oral & Maxillofacial surgery will change the way you look
Remodelling and Relapse after orthognathic surgery

JARGON ALERT!

Remodelling is where the soft tissue, that is attached to the bones of the face that have been moved, ‘remodels’ itself (changes its shape), perhaps reducing the benefit of the surgery.

Relapse is where the desired change in position of the bones of the face diminishes as the patient heals after the operation. Relapse is compensated for by over-correcting.

Both remodelling and relapse are effectively uncontrolled variables.

Osteotomy

The cutting of bone is called ‘osteotomy’. Surgery can be performed on the lower, upper or both jaws to treat sleep apnoea, as well as other conditions. This is sometimes referred to as orthognathic surgery.

For sleep apnoea, this is commonly to advance (bring forward) the lower jaw (mandible) to support opening the airway.

MMA = maxilla and mandible advancement surgery

JARGON ALERT!

MMA = Maxilla (upper jaw) Mandible (lower jaw) Advancement
If surgery is required on both jaws at the same time, it is called a bi-maxillary osteotomy (because bi-maxillary = both jaws). This is often called MMA.

This type of surgery, if performed on one jaw, will alter how your teeth fit together (your bite). This might be appropriate if your lower teeth are behind your upper teeth. If both jaws are moved together your bite may stay the same.

The surgical positioning adjustments of both jaws achieves a similar effect to multi-level surgery and may be considered an effective option when alternatives have failed or are not tolerated.

Figure 8: Bi-maxillary Osteotomy

Bi-maxillary osteotomy for sleep apnoea
This diagram shows how both jaws may be cut and repositioned to facilitate the opening of the airway, to resolve snoring and sleep apnoea. This surgery could be carried out on one or both jaws depending on what is needed to resolve the problem.
It is becoming increasingly recognised that MMA, although complex surgery, is one of the procedures capable of correcting severe OSA at all levels of obstruction, and is rapidly becoming the main surgical treatment for severe obstructive sleep apnoea, where CPAP has failed or is not tolerated and where mandibular advancement is helpful but not acceptable long term.

Hyoid suspension

The image below shows the hyoid bone in your throat – it is just above your thyroid cartilage your (“Adam’s Apple”).

Figure 9: Hyoid suspension

Hyoid-suspension-for-sleep-apnoea
The hyoid bone is attached by a ligament to the lower jaw. Surgery moves the ligament attachment forward, moving the hyoid forward, which brings the base of the tongue and epiglottis forward, to open the airway.
Surgery moves the ligament attachment forward, which in turn pulls the hyoid forward.
This brings the base of your tongue and epiglottis forwards, which may then open your airway, (only at this level in your airway), and overcome your sleep apnoea.23
If oro-maxillofacial surgery to advance the lower jaw is carried out, this will move forward the hyoid in a similar way.
Epiglottis is a flap of cartilage that protects your lungs from food and liquid entering.

JARGON ALERT!

The epiglottis is a flap of cartilage located in your throat behind your tongue. It is usually upright allowing air to enter your lungs.

When you swallow, it folds backwards to protect the entrance to your lungs so that food and liquid do not enter.

After swallowing, the epiglottis returns to its original upright position.

Tracheostomy

Historically, before PAP therapy, tracheostomy was the preferred treatment for obstructive sleep apnoea. A tracheostomy is a surgical procedure where a surgeon creates an opening in your neck, at the front of your throat, into your airway (known as your trachea).

PAP = positive airway pressure therapy

JARGON ALERT!

PAP = Positive Airway Pressure

Figure 10: Tracheostomy

Tracheostomy for sleep apnoea
Once the tube has been inserted into your airway, you will breathe through this tube, instead of through your mouth and nose.
A tube is inserted into this opening to help you breathe. This is major surgery as it bypasses the area that is prone to collapse (your airway behind your tongue), hence it is a last resort, as it may affect your ability to talk.

This operation should only be considered when other options do not exist, have failed, are refused, or when this operation is deemed necessary by clinical urgency 24.

Bariatric surgery

Being overweight or obese can detrimentally affect your life-expectancy.25 Excess weight is a significant contributing factor in sleep apnoea severity.

As OSA has been estimated to be present in 40%26 -90%27 of obese patients drastic options such as bariatric surgery to reduce the severity of sleep apnoea are now considered. This is serious surgery and should only be considered as a part of managing your overall care – thinking about more than just sleep apnoea. Bariatric surgery should only to be considered in addition to PAP or mouthpiece (oral appliance) therapy.28

It is indicated in patients with a BMI that is greater than or equal to 40 and in those with a BMI that is greater than or equal to 35 with other important medical problems (known as co-morbidities) who have found that changes in diet are inadequate.29,30

These BMI boundaries are occasionally changed upwards by funding bodies.
After the operation your nutritional intake may need to be monitored by your Doctor/PCP, 31 as such you may need continual use of supplements and perhaps even vitamin injections. Additionally, some patients may experience insufficient or too much stomach acid which may require the use of long term medications.

A tube is inserted into this opening to help you breathe. This is major surgery as it bypasses the area that is prone to collapse (your airway behind your tongue), hence it is a last resort, as it may affect your ability to talk.

This operation should only be considered when other options do not exist, have failed, are refused, or when this operation is deemed necessary by clinical urgency.24

OSA = obstructive sleep apnoea

ACRONYM ALERT!

OSA = Obstructive Sleep Apnoea
Bariatric surgery for sleep apnoea

ACRONYM ALERT!

BMI = Body Mass Index
Body Mass Index is a simple index of weight-for-height that is commonly used to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of the height in metres (kg/m2).

The World Health Organisation BMI classification is here: http://apps.who.int/bmi/index.jsp?introPage=intro_3.html

PCP = Primary Care Physician

Neural stimulation

There is a new, relatively unproven, surgical ‘quick fix’ known as HGN (hypoglossal nerve stimulation). The idea is that as the individual can maintain their airway when they are conscious, provision of an electrical stimulus to the tongue muscle while the patient is asleep, should keep their airway open.32

HGN = hypoglossal nerve stimulation for snoring

ACRONYM ALERT!

HGN = Hypoglossal nerve stimulation

Figure 11: Neural stimulation (HGN)

Neural stimulation for snoring

A wire runs up from a tiny pulse generator in your chest, and is attached to the hypoglossal nerve. This stimulates the nerve sufficiently to move your tongue forward to open your airway.

A tiny pulse generator is implanted in your chest and a wire run up under the skin of your neck to the nerve in your tongue (known as the hypoglossal nerve). A sufficient electrical pulse is delivered to make you stick your tongue forwards enough to open your airway.33

This is a new area and relatively unproven. Medical research trials are currently on-going, looking at two variations of this procedure.

One method requires perhaps more surgery as it needs the implanting of a ‘sensing’ lead to synchronise the electrical pulse to when you breathe in (inspiration).

The alternative approach, is to eliminate the sensing lead and avoid muscle fatigue, by varying where/how many sites of the tongue nerve receive the electrical impulse. 34

While HGN is an exciting new idea, further research is required, to thoroughly validate this option. The HGN device that has been approved to US market entry (it had already received regulatory approval in Europe).

In short, in a subset of moderate to severe OSA patients that have failed PAP can be considered for HGN stimulation.

Summary

Soft tissue surgery may be considered firstly for what is known as ‘simple’ snoring and secondly for snorers with OSA to either facilitate PAP therapy or overcome the obstruction. Should these approaches prove inadequate oral & maxillofacial surgery may be an option to change the underlying structure of your face, move the bones and open up the airway.

Surgery for obstructive sleep apnoea should only be considered when more conservative options have not worked. It is essential that a thorough examination and review of all your options has been undertaken and you view the operation holistically, considering your likelihood of disease progression and possible changes in your weight.

Understanding of surgical options is improving and consequently historically performed operations (uvulopalatopharyngoplasty) are less commonly funded by insurers today, due to difficulty identifying suitable patients beforehand35 and other options being available.

New options such as hypoglossal nerve stimulation (HGN) require further research but look promising, while pillar implants into your soft palate are currently not recommended for OSA in the UK but in the USA they may be considered for mild-moderate OSA.

Oral & maxillofacial surgery, tracheostomy and bariatric operations are normally only considered when all other avenues have been explored or are not tolerated.
In conclusion, obstructive sleep apnoea patients need on-going, long term management. OSA is a serious condition which affects many aspects of your life and health. Your condition may change and you may then need a different approach to use a therapy, manage the side-effects or perhaps, should a complication arise.

'Simple' snoring refers to snoring without obstructive sleep apnoea

MEDICAL TERMINOLOGY!

‘Simple’ snoring refers to snoring without obstructive sleep apnoea.
A thorough examination and review of all your options should be undertaken before surgery
Surgery for snoring references in the Appendix

References in the Appendix

Further information can be found in the References section of the Appendix at the end of this Snorer.com Guide.
Obstructive sleep apnoea patients need on-going, long term management

What next?

You might like to read the other Snorer.com Guides:

Want to find out if you have sleep apnoea, but worried about the impact on your medical records? We suggest you consider the Snorer.com ASAP Anonymous Sleep Apnoea Process™

Appendix

Acronym glossary

• BDS = Bachelor of Dental Surgery
• BMI = Body Mass Index
• DLO = Diploma in Laryngology and Otology
• ENT = Ear Nose Throat
• FDSRCS = Fellowship in Dental Surgery of the Royal College of
Surgeons of England
• FDA = Federal Drug Administration (USA)
• FRCS = Fellow of the Royal College of Surgeons
• HGN = Hypoglossal nerve stimulation
• LAUP = Laser assisted uvulopalatoplasty
• LRCP = Locum Royal College of Physicians
• M Phil = Master of Philosophy
• MAD = Mandibular Advancement Device
• MAS = Mandibular Advancement Splint
• MBA = Master of Business Administration
• MMA = Maxillomandibular Advancement
• MRCS = Member of the Royal College of Surgeons
• MRD = Mandibular Repositioning Device
• NHS = National Health Service (UK)
• NICE = National Institute for Health and Clinical Excellence
• OSA = Obstructive Sleep Apnoea
• PAP = Positive Airway Pressure
• PCP = Primary Care Physician
• UK = United Kingdom
• UPPP = Uvulopalatopharyngoplasty
• USA = United States of America

Surgery for snoring Appendix

JARGON ALERT!

These acronyms and others that you may come across are explained in the Snorer.com Jargon Buster!
https://snorer.com/jargon-buster/
References
References
1. Shneerson J, Wright J. Lifestyle modification for Obstructive sleep apnoea. Cochrane Database Syst Rev 2001;1:CD002875. [PubMed].
2. Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263-276
3. Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263-276
4. Sundaram S., Lim J., Lasserson T.J., (2005) Surgery for obstructive sleep apnoea in adults (Review), Cochrane database of systematic reviews, Issue 4
5. Chisholm E, Kotecha B Oropharyngeal surgery for obstructive sleep apnoea in CPAP failures. Eur Arch Otorhinolaryngol 2007; 264:1361-1367.
6. Gami AS, Caples SM, Somers VK. Obesity and obstructive sleep apnea. Endocrinol Metab Clin North Am 2003;32:869–894.
7. Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000;284:3015–3021.
8. Sundaram S., Lim J., Lasserson T.J., (2005) Surgery for obstructive sleep apnoea in adults (Review), Cochrane database of systematic reviews, Issue
9. Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263-276
10. Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263-276
11. Aurora R.N. et al (2010) Practice Parameters for the Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults, SLEEP, Vol. 33, No. 10.
12. NICE. Radiofrequency ablation of the soft palate for snoring. In progress. http://publications.nice.org.uk/radiofrequency-ablation-of-the-soft-palate-for-snoring-ipg124 [Accessed 27 July 2013]
13. NICE. Radiofrequency ablation of the soft palate for snoring (IPG124). Issued 25 May 2005. http://nice.org.uk/ipg124 [Accessed 26 August 2013]
14. Ryan CF: Laser assisted uvulopalatoplasty in sleep disordered breathing. Thorax 1997;52:5-8.
15. Littner M, Kushida CA, Hartse K, et al. Practice parameters for the use of laser-assisted uvulopalatoplasty: an update for 2000. Sleep 2001;29:244-62
16. NICE Guidelines re soft palate implants http://publications.nice.org.uk/soft-palate-implants-for-obstructive-sleep-apnoea-ipg241 [accessed 12 Oct 2012]
17. Choi, J. H., Kim, S.-N. and Cho, J. H. (2013), Efficacy of the pillar implant in the treatment of snoring and mild-to-moderate obstructive sleep apoea: A meta-analysis. The Laryngoscope, 123: 269–276. doi: 10.1002/lary.23470
18. Sundaram S., Lim J., Lasserson T.J., (2005) Surgery for obstructive sleep apnoea in adults (Review), Cochrane database of systematic reviews, Issue 4
19. Aurora R.N. et al (2010) Practice Parameters for the Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults, SLEEP, Vol. 33, No. 10.
20. Islam S; Uwadiae N; Ormiston IW. Orthognathic surgery in the management of obstructive sleep apnoea: experience from maxillofacial surgery unit in the United Kingdom. Brit J Oral Max Surg 2014; 52, 496-500.
21. Epstein LJ; Kristo D; Strollo PJ; Friedman N; Malhotra A; Patil SP; Ramar K; Rogers R; Schwab RJ; Weaver EM; Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263–276.
22. Islam S; Aleem F; Ormiston IW. Subjective assessment of facial aesthetics after maxillofacial orthognathic surgery for obstructive sleep apnoea. Brit J Oral Max Surg 2015; 53, 235-238.
23. Riley, R.W., Nelson B.P. and Guilleminault, C. Obstructive sleep apnea and the hyoid: a revised surgical procedure, Otolaryngology–head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery 111.6 (1994): 717.
24. Aurora R.N. et al (2010) Practice Parameters for the Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults, SLEEP, Vol. 33, No. 10.
25. Peeters, A. et al (2003) Obesity in Adulthood and Its Consequences for Life Expectancy: A Life-Table Analysis, Ann Intern Med. 2003 Jan 7;138(1):24-32.
26. Vgontzas AN, Tan TL, Bixler EO, Martin LF, Shubert D, Kales A. Sleep apnea and sleep disruption in obese patients. Arch Intern Med 1994;154:1705–1711.
27. Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg 2003;13:676–683.
28. Morgenthaler TI, Kapen S, Lee-Chiong T, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep 2006;29:1031-5
29. SAGES Guidelines Committee. Guidelines for clinical application of laparoscopic bariatric surgery: Society of American Gastrointestinal and Endoscopic Surgeons; 2008
30. Epstein LJ; Kristo D; Strollo PJ; Friedman N; Malhotra A; Patil SP; Ramar K; Rogers R; Schwab RJ; Weaver EM; Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3):263–276.
31. Mechanick JI, Kushner RF, Sugerman HJ et al (2008) American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract 2008; 14 Suppl 1:1-83
32. Mezzanotte WS, Tangel DJ, White DP. Waking genioglossal EMG in sleep apnea patients versus normal controls (a neuromuscular compensatory mechanism). J Clin Invest 1992;89:1571-79.
33. Schwartz AR, Eisele DW, Hari A, et al. Electrical stimulation of the lingual musculature in obstructive sleep apnea. J Appl Physiol 1996; 81:643-52.
34. Mwenge GB, Rombaux P, Dury M, et al. Targeted hypoglossal neurostimulation for obstructive sleep apnoea. A 1 year pilot Study. Eur Respir J 2012; May 17. [ Epub ahead of print]
35. Sundaram S., Lim J., Lasserson T.J., (2005) Surgery for obstructive sleep apnoea in adults (Review), Cochrane database of systematic reviews, Issue 4
Further reading
Monograph Sleep Apnoea (2010), chapter 17 and 18: http://erm.ersjournals.com/content/ermsa/1.toc
Kotecha, B. T, Hall, A. C; “Role of surgery in adult obstructive sleep apnoea” Sleep Medicine Reviews 18 405e413, 2014
Virk, J. S, Nouraei, R & Kotecha, B; “Multilevel radiofrequency ablation to the soft palate and tongue base: tips and pitfalls” European Archives of Oto-Rhino-Laryngology Volume 271:1809-1813, 2014
Arora, A. et al; “Outcome of TORS to tongue base and epiglottis in patients with OSA intolerant of conventional treatment” Sleep and Breathing – International Journal of the Science and Practice of Sleep Medicine, Volume 10, 2015
Strollo, P. J et al; “Upper-Airway Stimulation for Obstructive Sleep Apnea” New England Journal of Medicine, 370:139-149, 2014
Support groups
United Kingdom
• Sleep Apnoea Trust Association: http://www.sleep-apnoea-trust.org
• Scottish Association for Sleep Apnoea (SASA): http://www.scottishsleepapnoea.co.uk
• Irish Sleep Apnoea Trust: http://www.isat.ie
• Hope2Sleep: www.hope2sleep.co.uk
United States
• American Sleep Apnea Association: http://www.sleep-apnoea-trust.org
Legal statements

All trademarks are owned by their respective companies
and acknowledged.

Snorer.com gives you control
Control over how & when:
• Confidential access to independent information on snoring and sleep apnoea.
• How-to-Choose Guides without commercial bias.
Control over who knows:
• Anonymous, confidential access to sleep apnoea assessment.
Control over what:
• You control when and what to communicate about your results.

Surgery for snoring should only be considered when all other options have been tried and failed. Surgery some might think is a ‘quick fix’ yet it rarely is.

This free evidence-based Guide, co-authored by Professor Bhik Kotecha FRCS ↗ and Professor Iain Ormiston FRCS ↗, explains in a jargon-decoded way, what you need to know and what you might like to discuss about surgery beforehand.

Download our free Information Guide ‘Things to discuss when considering surgery for snoring or sleep apnoea.’ ↓ to understand the surgical options that might be or have been suggested to you.

This Guide explores the options to remove the worry of surgery, so that you can make informed decisions about your treatment.

Broadly speaking, surgery is usually considered either to improve upper airway anatomy to make Positive Airway Pressure (CPAP) therapy more effective or preferably to overcome the upper airway obstruction completely, so there is no need for CPAP therapy.

We’re proud that all of our Information Guides ↗ are accredited by the NHS Information Standard ↗, which is a quality mark supported by NHS England that helps people to choose reliable health and social care information.

Front cover of the Surgery Information Guide

Information Guide - Things to discuss when considering surgery for snoring and sleep apnoea

Download our free Information Guide.
In this Guide you’ll learn about testing and diagnosis, along with the different surgical options that might be recommended. These include soft tissue and oral and maxillofacial surgery, through to bariatric surgery and neural stimulation, along with a glossary and what to do next.

It is a MUST READ for anyone who is considering, or where surgical intervention has been recommended, to treat snoring or sleep apnoea. Because being in possession of clear, understandable information puts you in control. Adrian Zacher

Information Guide Co-Author, Snorer.com

Want to learn more?

Read our Snoring and Obstructive Sleep Apnoea Overview Guide ↗, which was Highly Commended in the British Medical Association Patient Information Awards in 2016.

Once you’ve read our Guides, you might like to test your knowledge with our deceptively simple quiz:

The Online Snoring Quiz ↗ is focused on snoring and sleep apnoea risk factors, diagnosis and treatment options.

Please take a moment and write a TrustPilot review, to help others find useful resources. Thanks!

What are you reviewing? Please enter its name

1 - 5 out of 5, where 5/5 is the best and 1/5 is the worst


Created by Emma Easton | Page last updated 21st Sept 2018