Surgery for Obstructive Sleep Apnea: One Size Doesn’t Fit All

Some patients with moderate or severe apnea should undergo uvulopalatopharyngoplasty (UPPP) along with the tonsillectomy, though mild disease could benefit from tonsillectomy alone, panellists said.

At the same time there is some risk that UPPP can lead to mouth leak in CPAP, especially at higher pressures, Dr. Mickelson said. Yet patients undergoing this are intolerant of CPAP in the first place. Realistically the goal of therapy is to improve patient survival. If they are not getting symptomatic relief from CPAP, then the only other alternative may be surgical. Sometimes the surgery is nasal alone, and not palatal.

Much of this depends on the goals of surgery, said Dr. Huntley. Usually my goal is to completely take care of OSA, to shoot for improvement in the sleep study parameters to the level obtained by CPAP. Sometimes this can be attained only with extensive stage surgery, which is sometimes not possible with some patients, or is more than what a patient will tolerate.

Dr. Weaver concurred, stating there is benefit if the surgery did not eliminate the OSA but allowed for more CPAP compliance, or resulted in lower, more comfortable pressures. The goals of surgery should be carefully discussed with patients preoperatively.

Determining the area of obstruction is far from an exact science, said Dr. Mickelson. But UPPP outcomes can be improved if it’s known whether the obstruction in a patient is in the palatal opening, palatal-tongue, or tongue only-all are worth testing for.

Panelists agreed that if multilevel surgery to the nose, palate, and tongue base is being considered, it is important to decide how to stage such surgeries. Sometimes it’s smartest to perform the nasal surgery first, letting it heal and seeing whether the patient can benefit from CPAP before considering further surgery. But which surgery comes first depends on patient characteristics and whether the goal is to help CPAP or do an airway correction.

Then there’s risk. Published data show that the more levels of surgery of the airway operated on at one setting, the higher the complication rate. Decisions as to how much to do at one setting must be made on a case-by-case basis.

You have to use your own critical judgement. You can defend either approach, but keep in mind why you are doing it, Dr. Weaver said.

There is also evidence suggesting that UPPP makes CPAP worse in isolated incidences, and this must be communicated to the patient preoperatively.