Surgical Treatment of Obstructive Sleep Apnea (1990)

Nasal continuous positive airway pressure (CPAP) has become the treatment of choice for obstructive sleep apnea (OSA), particularly in patients with severe daytime sleepiness and significant cardiopulmonary sequelae of the disorder. Retrospective analysis of mortality in OSA suggests that only tracheostomy and nasal CPAP change the natural history of the disorder, whereas uvulopalatopharyngoplasty (UPPP) does not change mortality rates when compared to untreated patients.1He J Kryger MH Zorick FJ Conway W Roth T Mortality and apnea index in obstructive sleep apnea.Chest. 1988; 94: 9-14Abstract Full Text Full Text PDF PubMed Scopus (1357) Google Scholar UPPP has been shown to be very effective in eliminating snoring, but several reviews have shown that objective documentation of complete resolution of OSA by polysomnography is uncommon with this procedure.2Guilleminault C Hayes B Smoth FB Palatopharyngoplasty and obstructive sleep apnea: a review of 35 cases.Bull Eur Physiopath Resp. 1983; 19: 595PubMed Google Scholar, 3Conway W Fujita S Zorick F Roehrs T Wittig R Roth T Uvulopalatopharyngoplasty: one year follow-up.Chest. 1985; 88: 385-387Crossref PubMed Scopus (100) Google Scholar Several groups have postulated that UPPP failure is due to the fact that the site of upper airway occlusion is not always limited to the oropharynx, and in some patients, obstruction may occur at multiple sites. Preoperative localization of the site of obstruction has been attempted with a variety of techniques, including fiberoptic nasopharyngoscopy,4Fujita S Conway WA Zorick FJ Sicklesteel JM Roehrs TA Wittig RM et al.Evaluation of the effectiveness of uvulopalatopharyngoplasty.Laryngoscope. 1985; 95: 70-74Crossref PubMed Scopus (204) Google Scholar somnofluoroscopy,5Katsantonis GP Walsh JK Somnofluoroscopy: its role in the selection of candidates for uvulopalatopharyngoplasty.Otolaryngol Head Neck Surg. 1986; 94: 56-60Crossref PubMed Scopus (58) Google Scholar CT scanning,6Shepard JW Thawley SE Evaluation of the upper airway by computerized tomography in patients undergoing uvulopalatopharyngoplasty for obstructive sleep apnea.Am Rev Respir Dis. 1989; 140: 711-716Crossref PubMed Scopus (97) Google Scholar and cephalometric x-rays with variable degrees of success in predicting the outcome of UPPP. In this issue of Chest (see page 1421) Riley et al discuss a preoperative approach that includes fiberoptic pharyngoscopy and lateral cephalometric x-ray examination to stratify patients according to the predominant site of obstruction. In patients with hypopharyngeal obstruction, surgical advancement of the facial skeleton and hyoid bone is performed in an attempt to expand the airway. In patients with obstruction at both the oropharyngeal and hypopharyngeal levels, mandibular maxillary and hyoid advancement was preceded by UPPP to eliminate oropharyngeal obstruction. In this report, 30 consecutive patients who were unable to continue nasal CPAP were treated with this type of evaluation and surgical protocol. Mean improvements in sleep-disordered breathing and sleep architecture after maxillofacial surgery were equal to those found after nasal CPAP Individual patient data reveal that respiratory disordered breathing index or number of disordered breathing episodes per hour of sleep was reduced to less than 20 in all patients. Daytime sleepiness and heavy snoring were also eliminated. The excellent results reported, however, were the product of a long, step-wise, progressively aggressive surgical approach including relief of nasal obstruction, UPPP, mandibular osteotomy and hyoid resuspension, inferior saggital mandibular osteotomy and bimaxillary advancement. A three- to six-month interval between stages of the surgery was used to assess success or failure so as to avoid unnecessary surgery. If maxillary, mandibular and hyoid advancement was required, postoperative morbidity was described as very low. Although hospitalization averaged only 2.4 days, jaw fixation for two to three weeks and orthodontic work to correct malocclusion secondary to surgery was necessary in all patients. A description of this approach to patients might serve to increase compliance with nasal CPAP! Despite its apparent aggressiveness, maxillofacial surgery was quite successful in this study. Surgical success in individual patients was also defined more rigorously than in past reports of UPPP by both subjective and objective polygraphic criteria. This success may be due in part to the experience of the surgical group involved. Therefore, confirmatory results on effectiveness and long-term sequelae of this approach from a multicenter trial would be quite helpful in determining the usefulness of these techniques in the significant number of sleep apnea patients who cannot continue with nasal CPAP therapy. How should patients who cannot use nasal CPAP be approached? A careful investigation into the causes of intolerance of nasal CPAP should be undertaken. Humidification, aggressive medical therapy of nasal dryness or congestion, rechecking of CPAP pressure and mask fit, and home monitoring of pressure level to assess effective CPAP therapy should all be attempted. If other conservative therapy such as weight loss and body position modification are also unsuccessful, surgical evaluation would be appropriate for the type of symptomatic patient with a high disordered breathing rate and significant baseline level of nocturnal desaturation, as in the consecutive group of patients noncompliant with CPAP described in this study. Sometimes nasal surgery alone may make CPAP more tolerable even if it does not improve the sleep-disordered breathing significantly. Rather than proceeding directly to UPPP, it would seem logical to try to localize the predominant site of obstruction using nasopharyngoscopy and cephalometric x-ray examination as relatively inexpensive and apparently effective preoperative staging techniques. UPPP should be reserved for those patients with isolated oropharyngeal obstruction. The nonobese, significantly retrognathic patient, unlikely to benefit from UPPP, seems to be a good candidate for mandibular advancement. As more centers become experienced with these techniques, more patients with multiple levels of airway obstruction during sleep may be candidates for the sequential surgical approach using UPPP and mandibular, maxillary and hyoid advancement outlined in this report, if they cannot continue on nasal CPAP.