Do you have sleep apnea or know someone who does?

It can be a challenge to find comprehensive and reliable information and we would like to help you.

This obstructive sleep apnea information guide was written by a sleep medicine provider.

In order to make this more helpful and as part of the research for this information guide, we searched the internet for frequently asked questions.

The goal of the blog post is to educate you on what obstructive sleep apnea is.

This blogpost provides illustrations that show the anatomy behind OSA and how it can be treated.

Upper airway that is open with normal breathing. Note that the oxygen goes into the airway and the carbon dioxide leaves the airway. CamachoMD.com
Upper airway that is open with normal breathing. Note that the oxygen goes into the airway and the carbon dioxide leaves the airway.

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Summary information for obstructive sleep apnea:

Obstructive sleep apnea (OSA) is when the upper airway is blocked during sleep. The upper airway starts at the nose and ends at the level of the trachea. By definition, an apnea is when the upper airway is blocked for at least 10 seconds in adults or 2 breath cycles in children.

Common areas of blockage in the upper airway include the soft palate, the adenoids, the uvula, the tonsils, and the tongue. In some cases (more commonly in children), the epiglottis or supraglottis can also contribute to obstructive sleep apnea.

The first-line treatment for obstructive sleep apnea varies depending on the particular cause, but tends to be continuous positive airway pressure (CPAP) therapy in adults and tonsillectomy (or tonsillotomy) with adenoidectomy in children.

Background:

What is snoring and what is obstructive sleep apnea?

Snoring is when the back of the throat vibrates and creates noisy breathing.

Most people have heard someone snore at one time or another.

Many people joke about snoring, but it can be a sign of a more serious disorder known as obstructive sleep apnea.

Obstructive sleep apnea is caused by the vibration, partial blockage or complete blockage of the tissues in the back of the throat. 

What is obstructive sleep apnea?

Obstructive sleep apnea is a common sleep disorder.  As the name implies, “obstructive” refers to partial or complete blockage of the upper airway during sleep.

Upper airway obstruction at the level of the soft palate and the tongue. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate and the obstructed tongue. CamachoMD.com
Upper airway obstruction at the level of the soft palate and the tongue. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate and the obstructed tongue.

Who gets obstructive sleep apnea?

Anyone can have obstructive sleep apnea.

There seems to be a genetic component to it given that OSA often runs in families.

There have been genetic markers that have been associated with OSA.[1, 2]

What are signs that someone may have obstructive sleep apnea?

  1. Repeated airway obstructions during sleep,
  2. Repeated awakenings during sleep,
  3. Choking during sleep,
  4. Gasping during sleep,
  5. Morning headaches,
  6. Loud snoring,
  7. Habitual snoring,
  8. Unrefreshing sleep, and
  9. Needing to urinate multiple times at night,

What are the symptoms of obstructive sleep apnea?

  1. Sleepiness
  2. Tiredness
  3. Morning headaches
  4. Neurocognitive impairment
  5. Unrefreshing sleep

Can obstructive sleep apnea raise blood pressure?

Yes, during apneas or hypopneas, some patients can have a physical response in which hormones are released such as metanephrines, which can cause the blood pressure to increase.

The elevated metanephrines can cause not only a nighttime increase in blood pressure but also a daytime increase in blood pressure.[3]

What problems can obstructive sleep apnea cause?

Air is supposed to move freely in and out of your body through your nose or your mouth while you sleep.

When someone has obstructive sleep apnea, then, by definition there is an obstruction in the airflow and the patient gets less oxygen and because they can’t breathe out as well either, they end up retaining carbon dioxide in their bodies.

Because of these repeated blockages, the oxygen levels can drop.

If the oxygen level in the mother drops, then it could potentially drop in the fetus as well.

Additional problems with obstructive sleep apnea:

Untreated obstructive sleep apnea can cause problems such as repeated drops in oxygen levels during sleep, frequent awakenings during sleep, tiredness, sleepiness, daytime fatigue, unrefreshing sleep, high blood pressure, and other problems.

What are physical findings that make someone more likely to have obstructive sleep apnea?

There are several physical features that can make someone more likely to have OSA.

First, the skeleton of the face.

If the patient has a smaller lower jaw or the lower jaw is set back, then this makes it so that the tongue is farther back than it would be in a person with a lower jaw that has a normal size and position.

Profile view of woman with normal upper jaw, but her lower jaw is set back more than normal (retrognathia). This will move the tongue back because the tongue is attached to the lower jaw. CamachoMD.com
Profile view (zoomed in) of a girl with normal upper jaw, but her lower jaw is set back more than normal (retrognathia). This will move the tongue back because the tongue is attached to the lower jaw.

Second, large tonsils and adenoids.

In children, OSA is commonly due to the enlargement of the tonsils and adenoids. Tonsils and adenoids are tissues that help the body fight infection.

However, since similar tissue is found in other areas of the body, the removal of the tonsils and adenoids hasn’t been found to increase the risk of immune system problems.[4]

Third, a large tongue can make it more likely that a person can develop OSA.

This makes sense since the tongue sits in the back of the throat, just above the vocal cords (where air enters into the trachea and then goes to the lungs).

Obesity has also been associated with OSA.

How is the upper airway blocked during apneas or hypopneas?

There are several levels of possible obstruction during apneas or hypopneas.

The upper airway starts at the nose and ends at the mid-neck.

So, any location starting at the nostrils and ending in the mid-neck can get blocked.

Blockages or obstructions come in three main forms:

  • Flow limitation,
  • Hypopneas, and
  • Apneas. 

Hypopneas occur when there is a reduction in airflow for at least 10 seconds and there is an associated reduction in oxygen.

Upper airway obstruction at the level of the soft palate. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate. CamachoMD.com
Upper airway obstruction at the level of the soft palate. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate.

Apneas occur when there is a 90% reduction in airflow (or more) for at least 10 seconds whether it is due to a blockage of the upper airway, or it could just be that the patient is not trying to breathe.

Obstructive apnea is when the apnea event is due to an obstruction in the upper airway – the sleep study will show effort (i.e. the chest is moving), but there is no airflow at the level of the nose.

Central apnea is when the apnea event is due to the lack of any effort to breathe (i.e. the chest is not moving), therefore, there is no airflow.

Unlike the definition in adults (lack of airflow for at least 10 seconds), an apnea or hypopnea in children is when the event lasts 2 breath cycles.

Flow limitation can be seen during respiratory effort-related arousals (RERAs).

During RERAs there is a partial upper airway obstruction that is counted during a sleep study when there is a respiratory event that doesn’t meet criteria for a hypopnea or an apnea.

RERAs are associated with a brain arousal (brain awakens, but the patient doesn’t necessarily need to awaken to the point of alertness).

Snoring is not counted into the apnea-hypopnea index for diagnosing obstructive sleep apnea. However, snoring is a sign of partial airway obstruction and causes noisy breathing. OSA patients almost always snore during the sleep study.

What are the severity categories for normal breathing compared to obstructive sleep apnea?

First, you need to know that obstructions that are counted during a sleep study are hypopneas and apneas. When you add up the total number of events and calculate the average per hour, the final number provides the apnea-hypopnea index.

Some sleep centers also score respiratory effort-related arousals and this would provide the respiratory disturbance index.

Obstructive sleep apnea can be diagnosed with either the apnea-hypopnea index or the respiratory disturbance index.

The total number of events and the severity are categorized as follows:

  • Normal breathing: 0 to <5 obstructions per hour of sleep,
  • Mild OSA: 5 to <15 obstructions per hour of sleep,
  • Moderate OSA: 15 to <30 obstructions per hour of sleep, and
  • Severe OSA: 30 or more obstructions per hour of sleep.

What areas are commonly obstructed in the upper airway?

Common areas of blockage in the upper airway include the soft palate, the adenoids, the uvula, the tonsils, and the tongue.

In some cases (more commonly in children), the epiglottis or supraglottis can also contribute to obstructive sleep apnea.

The structures of the upper airway that generally do not move, include the nose and the trachea (both ends of the upper airway).

The nose has cartilage, bone and soft tissues that can swell during sleep, but generally don’t vibrate.

Nasal polyps are a common exception to the rule as they are soft and could potentially vibrate during sleep.

The larynx is usually more rigid because it is composed of cartilage and tends not to vibrate unless the patient has soft tissue weakness (known as laryngomalacia).

So, the locations of airway blockages or obstructions during sleep tend to be the soft palate and uvula (the uvula hangs down from the soft palate) as they can both vibrate during sleep and can cause snoring.

In fact, the soft palate and uvula are the culprits for snoring in the majority of cases.

For patients with sleep apnea, the cause can be a limitation of the airflow or a complete blockage of the airway and then there is no airflow.

In the case of obstructive sleep apnea, the structures involved can be:

  • The soft palate (including the uvula),
  • The tonsils,
  • The tongue,
  • The epiglottis,
  • The supraglottis and
  • The entire throat (pharynx) could close off.

An ear, nose and throat surgeon (ENT, also known as an otolaryngologist) can evaluate the airway awake or during drug-induced sleep endoscopy.

Why does obesity increase the risk of obstructive sleep apnea?

Obesity is a risk factor for OSA because the upper airway becomes narrower when a patient gains weight.

This is an obese Down syndrome child (Trisomy 21). Note that the child is mouth breathing. Common facial features in Down syndrome include the flattened face, slanted eyes, epicanthic fold of the eyes, spots on the iris, tongue that protrudes, smaller ears, and a shot neck. CamachoMD.com
This is an obese Down syndrome child (Trisomy 21). Note that the child is mouth breathing. Common facial features in Down syndrome include the flattened face, slanted eyes, epicanthic fold of the eyes, spots on the iris, tongue that protrudes, smaller ears, and a shot neck.

Fat deposits in the upper airway when a person gains weight. Areas that fat deposits include the soft palate, the tongue and the walls of the throat itself (pharynx).

The fat deposits make the airway smaller, thereby making it more likely that the upper airway will become partially or completely obstructed during sleep.

Are there apps that let you listen to your snoring or nighttime breathing?

The first way to know if there is snoring is to ask the bedpartner.

If the snorer’s bed partner is complaining about the snoring, then already the risk of having sleep apnea increases since the snoring is generally loud and frequent by the time it becomes bothersome to others.

If you snore and want to listen to your snoring, you could consider downloading the app “Quit Snoring”, which has been found to be the highest rated app on iTunes based on a study that evaluated snoring apps.[5]   

You can also review the app platforms for yourself and read reviews to see which app best suits your needs.

Are there tests to check for snoring and obstructive sleep apnea?

The only way to know if you have obstructive sleep apnea is to have a sleep study.

If you have the symptoms listed above, then you should ask to be referred to a sleep medicine provider so that you can have a sleep study.

A home sleep study generally includes monitors for oxygen levels, breathing effort (generally a stretchy belt), heart rate monitors and a monitor for airflow (small tubing that is inserted into the nostrils).

A home sleep study is advantageous in that it allows the patient to remain in their home environment, which can make it easier to fall asleep than an in-lab sleep study.

Are there disadvantages to the home sleep study?

The disadvantage is that unlike an in-lab sleep study, home sleep studies don’t usually have brain wave monitoring or eye movement monitoring.

Therefore, the home sleep studies don’t show if the patient is asleep or awake, so overall a home sleep study is less sensitive in determining if a patient has obstructive sleep apnea than an in-lab study.

Note: If a home sleep study does not show sleep apnea, but the patient and healthcare provider believe that there may actually be sleep apnea, then the home sleep study can be repeated, or an in-lab sleep study could be ordered.

Because the in-lab sleep study is more expensive, it can be difficult to get these approved by insurance companies.

In-lab sleep study:

An in-lab sleep study is performed in a monitored sleep room (with video recording) and includes the same monitors as a home sleep study, however, the difference is that there are more monitors during an in-lab sleep study.

Additional monitors include electroencephalography (EEG) for monitoring brain waves, electrooculography (EOG) for monitoring eye movements, electrocardiography (ECG) for monitoring the heart, electromyography (EMG) for monitoring various muscles in the face, arms and legs. 

Even though there lots of wires and belts, the sleep study itself is not painful and patients should not fear to have the test done. 

How long before the results of the sleep study come back?

It can take 1-2 weeks for the results of a sleep study to come back.

This is because the sleep studies are scored in 30-second increments and there are many items to evaluate in the sleep study.

If it has been more than 2 weeks, then contact the sleep lab or the health care provider who ordered the study to discuss the findings.

Successful treatment of obstructive sleep apnea can improve the associated signs and symptoms.

It is important to have close follow-up with the treating health care provider when patients start treatment since there can be difficulties with therapy that can be improved with the help of the healthcare provider.

How does drug-induced sleep endoscopy help diagnose obstructive sleep apnea sites?

Sometimes it can be helpful for a sleep surgeon to take a patient to the operating room to evaluate the sites of obstruction during a drug-induced sleep endoscopy (DISE).

During a drug-induced sleep endoscopy, a patient is observed in the operating room, while they have a flexible fiberoptic endoscope in their nose.

The anesthesia provider will place an intravenous (IV) catheter and will then deliver anesthetic medications such as propofol and dexmedetomidine.

When the patient starts obstructing his or her airway, the sleep surgeon will introduce the flexible endoscope and will note obstructions in the upper airway starting from the back of the nose, down the upper airway, to the tissue just above the vocal cords called the supraglottis.

Once the areas of obstruction have been evaluated, the patient will either be awakened so the surgeon can discuss the findings when the patient is seen in the clinic; or if the patient and surgeon agreed to surgeries after the drug-induced sleep endoscopy procedure, then that could be performed after the DISE.

Medical Management

What happens if obstructive sleep apnea goes untreated?

The side effects and complications associated with not treating obstructive sleep apnea depend on the severity of obstructive sleep apnea.

In order to understand the complications, you need to remember the different categories of obstructive sleep apnea.

  • Mild OSA is 5 to <15 obstructions per hour,
  • Moderate OSA is 15 to <30 obstructions per hour, and
  • Severe OSA is 30 or more obstructions per hour.

In general, there tend to be fewer complications with mild OSA and more severe complications (cardiovascular) with severe OSA.

There are many medical treatments for obstructive sleep apnea.

Why do some patients with obstructive sleep apnea develop hypertension?

When humans sleep, there is normally a decrease in blood pressure.[3] However, with obstructive sleep apnea, patients could have an increase in blood pressure due to the increased sympathetic activity due to the repeated oxygen drops that cause the release of catecholamines (epinephrine, metanephrine, norepinephrine, and normetanephrine).[3]

How many times per hour does a patient need to obstruct their airway in order to be at higher risk for cardiovascular (heart problems)?

A study evaluating mortality found that patients with an apnea index of 20 or higher were at a greater risk of dying from untreated obstructive sleep apnea.[6]

Can obstructive sleep apnea cause a headache?

Yes. When a patient’s airflow is obstructed, they could have a decrease in oxygen and an increase in carbon dioxide in their bodies.

When carbon dioxide increases in the body, it can cause a headache. Typically, the headaches are worse when the patient wakes up and tend to get better as the day goes on.

What is positional therapy and how does it treat obstructive sleep apnea?

The simplest treatment in some cases is positional therapy.

The way to think about positional therapy is that it is meant to keep you off your back.

If you have positional obstructive sleep apnea, then the treatment can include side sleeping.

If your sleep study was performed in the lab, then they should be able to tell you if you have positional OSA.

Basically, when you have positional obstructive sleep apnea, there is blockage of the upper airway when you lie on your back, but when you lie on your side there are only a few or no blockages.

This makes sense because the tongue, soft palate, uvula, and other tissues can fall backward during sleep (due to gravity) and this can narrow the upper airway to the point that it obstructs.

By keeping you off your back, you are positioning your body you’re your throat) onto its side. The soft tissues (soft palate, uvula, tongue) shift toward one side because of gravity.

The position creates a passage for air to flow.

So, in the case of positional obstructive sleep apnea, you could be treated by sleeping with a bumper or with tennis balls on your back.

With bumpers, you wear a belt that has a “bumper” on the back that helps prevent you from lying on your back.

The concept is the same for tennis balls.

Basically, there are two methods for the tennis ball technique:

Place a tennis ball into a shirt pocket, then sew it shut and wear the shirt so that the ball is on your back so you don’t roll onto your back, and

Place one or more tennis balls into a sock and then sew it shut and then sew it to the back of a shirt so you don’t rollover.

Does the severity of obstructive sleep apnea affect treatment options?

It is important to note that the worse the obstructive sleep apnea, usually the worse the symptoms and problems.

However, that doesn’t mean that snoring alone, or snoring with mild obstructive sleep apnea should not be treated.

In general, mild obstructive sleep apnea can be treated with less invasive options such as positional therapy, oral appliances, and positive airway pressure devices (with lower positive airway pressure requirements).

Moderate and mild obstructive sleep apnea patients are usually not good candidates for positional therapy and usually will need to be started on positive airway pressure devices (with higher positive airway pressure requirements).

What are medical treatment options for obstructive sleep apnea based on the locations in the airway?

Obstructive sleep apnea treatments can be categorized based on the area of the airway that is treated, between the nose to the lower airway.

Nose treatments

  • Breathe rite strips
  • Nasal steroids (fluticasone, mometasone, flunisolide)
  • Sinus rinses (Neil med sinus rinses, Netti Pot, etc.)
  • Nasopharyngeal airway devices (nasal trumpets)
  • Positive airway pressure therapy

Tongue treatments

  • Myofunctional therapy (tongue, mouth and/or throat exercises)
  • Tongue retaining devices
  • Winx
  • Mandibular advancement devices (oral appliances)
  • Positive airway pressure therapy
Tongue retaining device woman lying down. Note that the device pulls the tongue forward, which opens the upper airway. Note: oxygen (blue) is able to come into her airway and carbon dioxide (green) is able to go out of the airway. CamachoMD.com
Tongue retaining device woman lying down. Note that the device pulls the tongue forward, which opens the upper airway. Note: oxygen (blue) is able to come into her airway and carbon dioxide (green) is able to go out of the airway.

Soft palate treatments

  • Myofunctional therapy
  • Winx
  • Mandibular advancement devices (oral appliances)
  • Positive airway pressure therapy

Uvula treatments

  • Myofunctional therapy
  • Winx
  • Mandibular advancement devices (oral appliances)
  • Positive airway pressure therapy
CPAP full facemask in man with a beard. There is no leaking of air and it is going into his mouth to keep his airway open. CamachoMD.com
CPAP full facemask in man with a beard. There is no leaking of air and it is going into his mouth to keep his airway open.

Tonsil treatments

  • Montelukast
  • Allergy management
  • Positive airway pressure therapy

Epiglottis treatments

  • Positive airway pressure therapy

Supraglottis treatments

  • Positive airway pressure therapy

Skeletal treatments

Mandibular advancement devices (oral appliances)

Maxillary expansion (using a device to expand the upper jaw, usually in children)

Can weight loss treat obstructive sleep apnea?

First, weight loss could potentially help; however, a rule of thumb is that 10% weight loss corresponds to about 25% improvement in OSA.

So, in most cases, it would take a significant amount of weight loss before the OSA is eliminated.

If weight loss is the chosen method of treatment, then other forms of therapy should be given until the weight comes off.

Once the weight is off, a new sleep study should be performed to ensure the OSA has either been eliminated or is at a very low level based on the determination of the sleep medicine provider.

What is the most common method for medically treating obstructive sleep apnea?

The gold standard medical treatment for obstructive sleep apnea is to use CPAP therapy.

Hypothetically, CPAP can eliminate obstructive sleep apnea in almost anyone.

Continuous positive airway pressure (CPAP) is basically the use of forced air (positive airway pressure) that goes from a compressor into your airway.

The new CPAP machines are quiet and can automatically adjust the amount of pressure you need based on feedback that the machine receives during your sleep if an automatically adjusting positive airway pressure device (APAP) is prescribed.

If only one pressure is prescribed, then it is true CPAP, which is not as commonly prescribed nowadays in the setting of APAP being available.

The machines are connected to your face via a mask and a hose.

The major problem with CPAP is that most or nearly most patients hate to use the machine and often will abandon treatment.

How do the positive airway pressure machines work?

For adults, treatment will typically begin with continuous positive airway pressure therapy also known as CPAP.

In reality, however, the new machines are more sophisticated and are actually auto-titrating or auto-adjusting positive airway pressure devices (APAP).

So, what is the difference between a CPAP and an APAP machine?

Well, a CPAP machine delivers one constant pressure throughout the night, while an APAP machine delivers variable pressures throughout the night based on what your body needs.

For example, if a patient undergoes a sleep study (polysomnography) and has severe obstructive sleep apnea, then the technician may start the patient on CPAP therapy that night.

Why do some patients have CPAP started during their sleep study?

During the diagnostic sleep study, some patients obstruct frequently, to the point that it is quite clear they have either moderate or severe obstructive sleep apnea.

In these patients, CPAP might be started during the study. If this happens, then the sleep study is called a split-night sleep study.

In a split night sleep study, the patient will wear CPAP and the technician will adjust the settings on the machine during the night in order to see what pressures work best for the patient.

Once the split-night sleep study is finalized, a pressure if often recommended.

If the sleep study recommends a pressure of 10 centimeters of water pressure for the CPAP setting, then many providers will just write for that pressure or they might write for a range of pressures (APAP machine).

What factors can cause the CPAP machine to require higher or lower pressures?

If a patient drinks alcohol one night, then they may require higher pressures.

If the patient loses some weight, they may require lower pressures.

Therefore, many sleep physicians will prescribe a range of pressures that include the recommended pressure.

For example, if the split-night sleep study recommends a pressure of 10 centimeters of water pressure, then the sleep physician may write the prescription for 8-12 centimeters of water pressure.

It is important to keep trying to use the machine as much as possible. Although the machines can be very challenging to adjust to, many patients find that their symptoms (i.e. sleepiness, fatigue, headache) tend to improve with time.

What are alternatives to positive airway pressure therapy?

In a systematic review, in which they searched for articles on the topic, the researchers found thirty-five major treatment options that included nose treatments, palate treatments, tongue treatments, jaw repositioning treatments, and several other medical and surgical options.[7]

Each of the options to treat obstructive sleep apnea targets a specific anatomical area of obstruction.

How do oral appliances work?

An oral appliance, also known as a mandibular advancement device, is a device that is placed into the oral cavity and the device moves the lower jaw forward.

By moving the lower jaw forward, the oral appliance helps to open the airway since the tongue moves forward and the palate and uvula also move forward (because there is a muscle [palatoglossus] connecting the tongue to the palate is stretched and this pulls the palate forward).

The advantages of using oral appliances include that they do not require batteries or power supplies, and they are easy to transport.

However, it has been found that oral appliances are best for patients with mild or moderate obstructive sleep apnea, and they are not generally recommended for patients who have severe obstructive sleep apnea as the initial treatment because they are less effective for them.[8]

What surgeries can be done treat (or to improve) obstructive sleep apnea?

There are over fifty surgeries that can be performed as a treatment for obstructive sleep apnea.

In general, surgeries target the following areas:

  • Nose,
  • Soft palate,
  • Uvula,
  • Tonsils, and
  • Tongue tonsils (base of tongue)
  • Epiglottis, and
  • Supraglottis.

Targeting the tonsils is recommended as the first treatment by the American Academy of Sleep Medicine if the patient has large tonsils.[9]

Nose surgeries:

  • Rhinoplasty,
  • Septoplasty, and
  • Sinus surgery
Large uvula being trimmed to a more normal length. Given that the uvula is about 2 centimeters, in this illustration it is being trimmed to about 1 centimeter. CamachoMD.com
Large uvula being trimmed to a more normal length. Given that the uvula is about 2 centimeters, in this illustration it is being trimmed to about 1 centimeter.

Palate surgeries:

  • Uvulopalatopharyngoplasty (UPPP),
  • Laser-assisted uvuloplasty (LAUP),
  • Cautery assisted uvuloplasty (CAPSO),
  • Pillar implants,
  • Partial or complete uvulectomy,
  • Z-palatopharyngoplasty (ZPP or ZPPP),
  • Lateral pharyngoplasty, and
  • Transpalatal advancement pharyngoplasty

Oropharyngeal surgeries:

  • Tonsillectomy, and
  • Tonsillotomy
Tonsillectomy. The left tonsil has been removed and the black arrow is pointing to the tonsil wound bed (the lines represent the superior pharyngeal constrictor muscle). CamachoMD.com
Tonsillectomy. The left tonsil has been removed and the black arrow is pointing to the tonsil wound bed (the lines represent the superior pharyngeal constrictor muscle).

*Note: In children, an adenoidectomy is also performed with tonsillectomy as standard practice.

Tongue surgeries:

  • Tongue repositioning surgeries,
  • Base of tongue reduction surgeries,
  • Non-base of tongue reduction surgeries, and
  • Hypoglossal nerve stimulator placement surgeries

Epiglottis surgeries:

  • Shrink the size of the epiglottis (partial epiglottectomy),
  • Repositioning (epiglottopexy), and
  • Other epiglottis surgeries (epiglottoplasty)

Supraglottis surgeries:

  • Debulking of the supraglottis tissues

Hyoid surgeries:

  • Suspension of the hyoid, or suturing of the hyoid down to the thyroid cartilage

Skeletal surgeries:

  • Genioglossus advancement,
  • Maxillary advancement,
  • Mandibular advancement,
  • Maxillomandibular advancement,
  • Maxillary expansion, and
  • Sliding genioplasty (sliding the lower chin forward)
Sliding genioplasty. In this case, the cut of the bone included the genial tubercle. There are plates and screws in place, holding the bone forward. CamachoMD.com
Sliding genioplasty. In this case, the cut of the bone included the genial tubercle. There are plates and screws in place, holding the bone forward.
Maxillomandibular advancement showing the split after the maxilla (upper jaw) and mandible (lower jaw) have been cut and moved forward. The plates and screws are shown with blue color. The inferior alveolar nerve is shown in yellow. CamachoMD.com
Maxillomandibular advancement showing the split after the maxilla (upper jaw) and mandible (lower jaw) have been cut and moved forward. The plates and screws are shown with blue color. The inferior alveolar nerve is shown in yellow.

Which surgeries are the most effective?

Two major surgeries that can significantly improve OSA are maxillomandibular advancements (MMAs) and tracheostomies.

Maxillomandibular advancement is a jaw surgery in which cuts are made in the upper and lower jaw and they are moved forward. MMAs open the upper airway front to back and side to side.

In a tracheostomy, there is the creation of an opening between the skin of the neck and the trachea (windpipe). It can be a temporary or permanent opening. 

Tracheostomy tube in the neck showing airflow. Oxygen in blue is going toward the lungs and carbon dioxide is going away from the lungs. CamachoMD.com
Tracheostomy tube in the neck showing airflow. Oxygen in blue is going toward the lungs and carbon dioxide is going away from the lungs.

Rarely, if a patient needs the tracheostomy for years and years, or permanently, then some of the tissue deep to the skin can be operated on and a permanent opening (stoma) can be created.

The way it works is that a tracheostomy bypasses the upper airway and a tube sticks out of the neck and this tube allows clear breathing so the airway remains open during sleep.

Is surgery as effective as positive airway pressure therapy as a treatment for obstructive sleep apnea?

The most effective surgery is a tracheotomy.

Tracheostomy is the surgery most likely to cure OSA is a tracheostomy since it bypasses the upper airway.

It was commonly performed in the 1970s and 1980s but then was phased out for the most part since the development of several alternatives.

Currently, it is quite rare for a patient to have a tracheostomy. However, there are specific patients and circumstances in which a tracheostomy may be indicated.

Does maxillomandibular advancement permanently cure OSA?

Maxillomandibular advancements are generally more effective than the other sleep surgeries, but involve cutting the bone of the upper and lower jaw, with possible lifelong numbness of the chin and can change the appearance of the face.

A study reviewing the international literature found that obstructive sleep apnea is dramatically improved after MMA (from severe down to mild OSA), but can recur to a moderate OSA level after 8 years.[10]

Government Disclaimer: The views expressed in this website are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References

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2.            Xu, H., et al., A systematic review and meta-analysis of the association between serotonergic gene polymorphisms and obstructive sleep apnea syndrome. PLoS One, 2014. 9(1): p. e86460.

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