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surgery option
A young friend of mine, age 25, was just diagnosed with sleep apnea. The ENT she's seeing says that surgery would be a "better long-term option than the mask." I say, why not go with the least invasive first and see if that works, before you get what sounds like pretty major surgery?
Thoughts from the experienced ones here?
Anne Pf.
Thoughts from the experienced ones here?
Anne Pf.
Views: 39
Replies to This Discussion
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Permalink Reply by sleepycarol on
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I agree with you Anne. Of course it is personal choice, but I know I do not like having invasive surgery when other options are available. I have heard that many times surgery is just a short term fix as many still have to use their cpaps -- with a higher pressure.
Have her research it carefully.
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Permalink Reply by Oyvind on
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I had surgery, it did not help my case completely, but I now breath more easy. If he is only 25,and the doctor believes that surgery will help I would go for that. It sure beats having to be dependent on a machine for the next 50+ years.
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Permalink Reply by Mike on
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ask your friend what kind of surgery we're talking about here. some are pretty medieval -- breaking open the jaw, re-shifting it, then sewing you back up with recovery time of a few months, and a liquid only diet for that time too. some are less invasive.
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Permalink Reply by Steven Y. Park, MD on
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There are a lot of misconceptions with ENTs and sleep doctors about surgery. Without getting into the standard debate over whether or not one should even do surgery ... OK, I will. This may be an overgeneralization, but most ENTs still focus too much on palatal procedures (snoreplasty, implants, LAUP, UPPP, etc.) without looking other areas of the upper breathing passageways, including the tongue and the nose. For most people with sleep apnea, they're all connected to various degrees, so you have to address all these area simultaneously. This is slowly changing, but it will take time. It's also frustrating to explain this concept to sleep doctors, who don't appreciate the upper airway from an anatomic standpoint. Of course, there are exceptions with certain doctors.
If you do a UPPP only, the surgical "success" rate is only 40%. Success is defined at the final AHI dropping by more than 50% and the final number less than 20. This makes sense if you start around 60, but what if you start at 19, or even 7? Also, one of the major criticisms of sleep apnea surgery is that even if you go from 49 to 6, you still have mild sleep apnea. The other camp counters by saying that 6 is better than not being able to use CPAP at all. But all this is based on older research examining palatal level surgery only.
Dr. Friedman has a staging system that can predict whether or not you'll respond to UPPP/tonsil surgery only. Essentially, if your tongue sits very low in the mouth (you can see most of your tonsils) and you have relatively large tonsils, you have about an 80% chance of "success" with a UPPP. Most children will fall into this category. Most adults will not due to decent of the voice box. The main reason why UPPP fails in most people is that you're not addressing the tongue base area. Talking about whether or not UPPP works for sleep apnea is an inappropriate question to ask, unless you address the tongue base as well. Surprisingly, there are still papers being published about UPPP efficacy, quality of life, complications, etc. You also have to address the nose, since having nasal congestion can aggravate palate and tongue collapse downstream. Sometimes, just by addressing the nose, patients can eventually use CPAP or their dental devices more effectively.
At Stanford, where they pioneered multi-level surgery, their "success" rates are 75-80%. It doesn't really matter which procedure you use—what matters is that you deal with the tongue definitively. At Stanford, they do a hyoid suspension in addition to a mandibular osteotomy with genioglossus advancement. You can also do a Repose suture, or Somnoplasty (must be done multiple times for good results). A more aggressive surgery is maxillo-mandibular advancement, where both your upper and lower jaws are moved forward. This gets about 90-95% success rates, some with indexes going into the low single digits. Tracheotomy is 100% effective. So technically, surgery can work, but it depends on how appropriately and aggressively you address the proper areas. You can either shrink the soft tissues inside the mouth, or enlarge the jaws, or bypass it altogether.
As a surgeon, my first priority is to do everything possible to avoid surgery. Patient with sleep apnea should be given every opportunity to start with CPAP, with proper follow-up and support. It's time and labor intensive, but worth it. Dental devices are also underutilized. Surgery should be an option of last resort, but once you've tried everything there is to do with CPAP and dental devices, what other options do you have? Surgery will not cure you, but significantly lowering your numbers, even if you still have some apneas, can dramatically change the quality of your life. Think about all humans as being on an upward continuum for sleep-breathing problems. I see surgery as shifting that diagonal line downwards, but as you get older, you'll slowly keep creeping up that line (with most modern humans as our upper airway sags and collapses). Even if you use CPAP, you'll keep moving up.
A study done in the VA done a while ago followed people who were given CPAP and the other group underwent a UPPP. After a number of years, the group that was given CPAP had a slightly higher death rate. Granted there are a lot of variables here, but the results are not surprising: 40% of the UPPP group have significant improvement immediately, but not everyone in the CPAP group benefited from this option due to compliance issues.
My feeling is that it's not a CPAP vs. surgery issue. It's offering patients the best possible treatment option first (which is CPAP), and doing everything possible to facilitate this, but be able to understand the other options to be able to offer it when necessary, from more conservative to more aggressive options. The technical aspects of CPAP and surgery are important, but the doctor also has to develop good relations with the patient, to understands their wants and needs, and to personalize a treatment plan (including lifestyle issues, diet, exercise, stress management, etc.) that's most appropriate for the patient. I realize these are lofty goals, but worthwhile shooting for.
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Dr. Park,
That is why you are such an important part of this forum. You look at the whole picture and not just fragments. You give valid reasons and do not try to force one option over another. We need your continued support on this forum so that patients can be as knowledgeable as possible on the different treatment options including cpap, surgery, dental devices, etc.
Again thanks for the input.
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Permalink Reply by Duane McDade on
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Surgery is about 40% successful....I have even seen patients get worse. It all comes down to finding your obstruction and altering or removing it. In some patients multiple obstructions are the problem. Patients have gone off and had surgery and returned for follow up sleep studies with little or no improvement.
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IDr Park's post gives all the information you need to evaluate surgery from a doctor's point of view, and his feedback from patients. My experience with UPPP surgery had results I would like to share with anyone contemplating that surgery. The ENT who had done several previous sinus surgeries, told me that a surgery he did could ABSOLUTELY cure sleep apnea. I asked my Internist opinion - a resounding NO. I listened to the one whose opinion agreed with what I wanted to hear. The ENT surgeon's reported "increased the width of the airway, blocked some muscle activity to allow airway to remain open,& removed uvula and soft palate tissue which was obstructing airway.. Scraped tissue to bone.trimmed airway tissue.
He told me it was minor surgery. Perhaps it was me, but it took several weeks to recover. I had nausea with pain meds, and had to stop. penetrating pain for 10 days. Now food or liquid can reguritate into upper nasal passages. Particles of vegetables/protein can remain for 10 days. choke frequently on liquids. My sleep apnea has lessened, but went through all that, and still have to have cpap. If you are considering this type of surgery, please have the tests my ENT did not do. Endescopy to determine if tongue and soft palate are both envolved. Skull x-rays to determine jaw position. I would never consider this type of surgery again. still have to used cpap. .
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I went to an ENT to see about getting surgery for my sleep apnea. He requested a copy of a previous sleep study from my family doctor. ONLY THEN was I told that what I had was central, and not obstructive, sleep apnea - so surgery would not help. This sleep study was MONTHS old, but I was never told nor was I given a copy. MAKE SURE you ask your doctor for a copy of your study and read it! Then ask questions!!!!
My answer to AnnePf - make sure you do in fact have only obstructive sleep apnea - then try the mask first. Surgery should be last and only if the mask just doesn't work.
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Hi Anne,
My understanding is that CPAP can fail, eventually, as well. I know several folks who use it and they continually need their pressure raised. My brother in law is at the highest setting and although he had initial success years ago with the CPAP, he feels he is back to square one. He will not consider surgery though.
My sleep study showed that I have stopped breathing several times in an hour for as long as 40 seconds. And I had over 72 events an hour. In a 7 hour sleep study, I never went past stage 2 of sleep and only managed about two hours of sleep, and it was not consecutive sleep time. The idea of the stress this put on my heart scared the heck out of me. I am 42 years old.
I am currently recovering from UPPP, tonsillectomy and somnoplasty. I knew I would not be able to tolerate wearing a mask long-term and am fortunate to live in an area where several reputable surgeons are available to perform these procedures. MY ENT said that my airway was VERY narrow. It was a tough surgery, accompanied by a lot of pain, that was managed with narcotics. The surgeon thoroughly explained the procedures and recovery and so far everything has gone as he said it would. I'm a bit inpatient though and still do not have restful sleep. I'm only a month out from surgery and I know I still have some recovering to do. I'm anxious for the follow up sleep study to see if there is any improvement.
I read a lot of research on this topic and realize I may have to undergo additional procedures to get the desired results. My main reason for deciding to go through with the surgery, aside from not tolerating the CPAP, is that I wanted to correct the anatomical issues that were brought to my attention. I always had an awareness of my throat (it felt tight) and it began to really irritate me as I got older. Every little sinus infection or slight sore throat would close up my throat. I didn't have a lot of throat infections but, when I did have the occasional cold, I struggled and had to to sleep sitting up because it felt as if my airway was closing up. I also had asymetrical tonsils that were enlarged and the ENT said it was best to remove them.
I should also mention that, although my jaw appears to be anatomically correct, I do have degenerative joint disease of the TMJ (I have had 5 bilateral arthroplasties in 20 years and may need to have partial joint replacement in the next 5 years). I am only now wondering if there is a connection to the stability of my jaw playing a role in the collapse of my airway when I sleep. I plan to discuss this with the ENT and Oral Surgeon pending the results of the follow up sleep study.
There may several variables that go into deciding whether surgery is right for your friend. They should carefully weigh all of those reasons. I wish your friend the best.
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