# Surgical Management of Adult Obstructive Sleep Apnea

## Introduction

Surgical intervention for **obstructive sleep apnea (OSA)** is considered when positive airway pressure therapy and oral appliances fail or are not tolerated. The goal of surgery is to reduce or eliminate sites of upper airway obstruction. Modern OSA surgery employs a **multilevel, individualized approach** guided by preoperative anatomic assessment and **drug-induced sleep endoscopy (DISE)**.

## Patient Selection and Preoperative Assessment

### Indications for Surgery

Failure of or intolerance to CPAP and oral appliance therapy. Identifiable anatomic obstruction amenable to surgical correction. AHI >= 15 or AHI 5-14 with significant symptoms or comorbidities. Patient preference after counseling on risks and expected outcomes.

### Preoperative Evaluation

**DISE**: Identifies dynamic collapse patterns (retropalatal, retrolingual, epiglottic, lateral pharyngeal wall). Cephalometric analysis for skeletal relationships. **Mueller maneuver**: Flexible nasopharyngoscopy during forced inspiration with closed nose and mouth. BMI assessment; optimize weight before elective surgery, Cardiovascular risk stratification.

## Nasal Surgery

Nasal obstruction contributes to OSA and reduces CPAP tolerance. **Septoplasty**, **turbinate reduction**, and **nasal valve repair** improve nasal airflow. Nasal surgery alone rarely cures OSA but serves as an adjunct to improve CPAP adherence and oral appliance efficacy. Functional endoscopic sinus surgery may address concomitant chronic rhinosinusitis.

## Palatal Surgery

| Palatal Procedure | Mechanism | Key Advantage | Success Rate |
|-------------------|-----------|---------------|-------------|
| UPPP | Removes soft palate, uvula, tonsils | Widely available | 40-50% standalone |
| Expansion sphincter pharyngoplasty | Rotates palatopharyngeus superolaterally | Addresses lateral wall collapse | Superior to UPPP |
| Lateral pharyngoplasty (Cahali) | Divides superior constrictor | Lateral wall opening | Good for lateral collapse |
| Barbed reposition pharyngoplasty | Barbed suture repositioning of palatopharyngeus | Less invasive | Promising (data emerging) |

### Uvulopalatopharyngoplasty (UPPP)

Most commonly performed sleep surgery historically, Removes redundant soft palate, uvula, and palatine tonsils. Success rate approximately **40-50%** as stand-alone procedure (Sher criteria: AHI reduction >50% and AHI <20). Poor results when retrolingual or epiglottic collapse is the primary site. Complications: Velopharyngeal insufficiency (VPI), dysphagia, globus, nasopharyngeal stenosis.

### Expansion Sphincter Pharyngoplasty (ESP)

Lateral pharyngoplasty technique that rotates the **palatopharyngeus muscle** superolaterally. Addresses lateral pharyngeal wall collapse, which UPPP does not target. Partial uvulectomy and tonsillectomy combined with muscle transposition. Superior outcomes compared to traditional UPPP for lateral wall collapse.

### Lateral Pharyngoplasty (Cahali)

Divides the superior pharyngeal constrictor to release lateral wall tension. Enlarges the retropalatal airway laterally, Can be combined with tonsillectomy and palatal procedures.

### Barbed Reposition Pharyngoplasty (BRP)

Uses barbed sutures to reposition the palatopharyngeus muscle anterolaterally. Less invasive technique with promising short-term results, Ongoing studies evaluating long-term durability.

![Expansion sphincter pharyngoplasty technique showing palatopharyngeus rotation](images/esp-technique.jpg)

## Tongue Base and Hypopharyngeal Surgery

### Tongue Base Reduction

**Transoral robotic surgery (TORS)**: Midline posterior glossectomy using the da Vinci surgical system. Excellent visualization and access to the tongue base and epiglottis. Removes 1-2 cm wedge of tongue base tissue. Can address lingual tonsil hypertrophy. **Radiofrequency ablation (RFA)**: Volumetric reduction of the tongue base with interstitial thermal energy. Office-based or operative; multiple sessions may be needed. Less effective than TORS for moderate-to-severe OSA.

### Epiglottic Surgery

**Epiglottoplasty**: Partial epiglottectomy or suture epiglottopexy for epiglottic collapse identified on DISE. Anterior-posterior epiglottic prolapse (trapdoor pattern) most amenable to surgical correction. Performed via TORS or direct laryngoscopy.

### Genioglossus Advancement

Advances the genial tubercle (attachment of the genioglossus) anteriorly. Rectangular osteotomy of the anterior mandible capturing the genial tubercle. Increases tension on the genioglossus, pulling the tongue base forward. Often combined with hyoid suspension.

### Hyoid Suspension

**Hyothyroidopexy**: Sutures the hyoid bone to the thyroid cartilage. **Hyomandibulopexy**: Suspends the hyoid to the mandible. Expands the retrolingual airway. Adjunctive procedure; rarely performed in isolation.

## Skeletal Surgery

### Maxillomandibular Advancement (MMA)

**Most effective single surgical procedure** for OSA (success rate 85-100%). Bilateral sagittal split osteotomy of the mandible with Le Fort I osteotomy of the maxilla. Advances the entire skeletal framework by **10-12 mm**, expanding the airway at all levels. Reserved for severe OSA, patients with craniofacial skeletal deficiency, or failure of soft tissue surgery. Complications: Malocclusion, numbness (V3), facial profile change, nonunion. Orthodontic planning often required pre- and postoperatively.

![Lateral cephalogram demonstrating maxillomandibular advancement for OSA](images/mma-cephalogram.jpg)

## Tracheotomy

**Definitive surgical treatment** for OSA; bypasses all sites of upper airway obstruction. Reserved for morbidly obese patients, severe OSA with life-threatening desaturations, or failure of all other interventions. Reduces AHI to near zero. Significant quality-of-life implications; used as last resort.

## Multilevel Surgery

Most patients have obstruction at **multiple anatomic levels**. Combining procedures (e.g., palatal surgery + tongue base reduction + nasal surgery) improves overall success rates to **60-80%**. **DISE-directed surgery**: Identifies the specific collapse pattern to guide procedure selection. Staged approach (palatal surgery first, then tongue base) versus simultaneous multilevel procedures.

## Outcomes and Success Criteria

**Sher criteria**: Reduction of AHI by >50% and final AHI <20. **Surgical success rates** vary by procedure and patient selection. Postoperative PSG should be performed **3-6 months** after surgery to assess outcomes. Weight gain after surgery may diminish long-term results. Adjunctive CPAP at lower pressures may be needed even after successful surgery.

![Algorithm for surgical management of adult OSA based on DISE findings](images/osa-surgical-algorithm.jpg)

## Key Clinical Pearls

DISE is essential for identifying the specific sites and patterns of obstruction to guide surgical planning. MMA is the most effective surgical procedure for OSA but is reserved for appropriate candidates due to its invasiveness. UPPP alone has a poor success rate (~40-50%) because it does not address retrolingual or lateral pharyngeal wall collapse. Modern OSA surgery is multilevel and tailored to the individual patient's anatomy and collapse patterns. Postoperative polysomnography is mandatory to objectively assess surgical outcomes.

## References

1. Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. *Sleep*. 2010;33(10):1396-1407.
2. Vicini C, Dallan I, Canzi P, et al. Transoral robotic tongue base resection in obstructive sleep apnea-hypopnea syndrome. *Eur Arch Otorhinolaryngol*. 2012;269(1):381-386.
3. Holty JE, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. *Sleep Med Rev*. 2010;14(5):287-297.
4. Kezirian EJ, Hohenhorst W, de Vries N. Drug-induced sleep endoscopy: the VOTE classification. *Eur Arch Otorhinolaryngol*. 2011;268(8):1233-1236.