Can surgery fix sleep apnoea? Exploring your options

Quick Takeaways:

• Surgery isn’t usually the first treatment option for sleep apnoea. Most people start with CPAP therapy or an oral appliance to keep the airway open during sleep.
• For some, surgery may help when other treatments aren’t successful. It may help improve airflow by removing or repositioning tissue that blocks the airway.
• Different surgeries target different areas — such as the nose, throat or tongue — depending on what’s causing the blockage.
• Talk with your doctor about the benefits, risks, and recovery process to see if surgery is the right fit for you.

If you have been diagnosed with sleep apnoea, you might be curious about your treatment options.

Continuous positive airway pressure (CPAP) therapy delivers mild air pressure to keep your breathing airways open while you sleep. ²³ CPAP therapy is highly effective and is the most used and understood method for treating obstructive sleep apnoea (OSA).²⁴ OSA is a condition where your upper airway becomes blocked repeatedly during sleep, making it harder for air to flow. These blockages can reduce or completely stop the flow of air, causing your breathing to pause throughout the night. ²⁵

If CPAP therapy isn’t a good fit, another treatment approach is an oral appliance. Oral appliances for sleep apnoea can help keep your airway open by shifting the lower jaw forward while you sleep.

If neither of these treatment options work for you, your doctor may recommend surgery. Multiple surgical techniques can be used to treat obstructive sleep apnoea, each of which is covered in more detail below.

Understanding surgical interventions for sleep apnoea

While it’s not usually the first choice, surgery for OSA may be considered when other, less invasive options haven’t provided enough benefit. Here are some things to consider about sleep apnoea surgery.

What is sleep apnoea surgery?

Sleep apnoea surgery aims to improve airflow by addressing areas that may block the airway during sleep. Depending on the approach, this may include the nose, soft palate, tongue or throat. Surgery may help clear blockages, increase airway size or reduce tissue collapse to help support breathing during sleep.

CPAP is widely recognised as the most recommended type of therapy for people with OSA, including individuals with more than one condition impacting their health (also known as comorbidities). Surgery is typically only recommended when CPAP therapy or other treatments have not provided enough benefit or comfort. Anyone considering surgery for obstructive sleep apnoea should talk to a sleep specialist to determine if they are a good candidate and to weigh the risks and benefits.

Selection and evaluation

Different types of tests may be used to help decide whether sleep apnoea surgery is appropriate and to plan the best approach. These tests may include:²

• Physical examination to identify any blockages in the airway
• Overnight sleep test to confirm sleep apnoea diagnosis and severity
• Drug-induced sleep endoscopy (DISE), in which a doctor uses a tiny camera to look at your airways while you’re in a sleep-like state
• Assessment of body mass index (BMI) and other conditions that might affect whether you’re a good candidate for surgery

The role surgery plays in sleep apnoea treatment

When it comes to treating obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is typically the first choice, followed by oral appliances. Sleep apnoea surgery is generally considered a last resort option.¹

If you are considering surgery, it can be important to remember that, while surgical procedures can provide relief for some people, they are not universally effective. Often, surgery options depend on individual body structure and OSA severity. That said, surgery may be successful in one person but not another.²⁶

Surgery may not eliminate OSA, and other therapies and management approaches may still be needed after surgery. If you are considering sleep apnoea surgery, talk to your doctor about success rates and the potential need for multiple procedures.

Surgical procedures for sleep apnoea

Surgeries for OSA focus on different parts of the upper airway — generally the nose, mouth and throat. Here are some of the options.

Nasal and sinus procedures

For some people, blockages in the nose and sinuses may contribute to OSA. Procedures to help address these obstructions include³:

• Septoplasty to correct a deviated septum (when the wall between your nostrils is off-centre, which can make breathing difficult).
• Turbinate reduction to shrink swollen tissue inside your nose, which improves nasal airflow and helps you breathe easier.
• Nasal valve surgery to strengthen the narrowest part of your nasal airway, preventing it from collapsing when you breathe in through your nose.
• Sinus procedures to treat and reduce symptoms of chronic sinusitis (inflammation in the sinuses that makes it hard to breathe through your nose).

These procedures may be performed in combination with other surgeries to make CPAP more comfortable and easier to use. In fact, in one study, nearly every participant’s experience with CPAP improved after having nasal and sinus procedures.³

Palate and pharyngeal procedures

Other OSA surgeries focus on the roof of the mouth (palate) or the part of the throat behind the mouth and nose (pharynx). Most of these procedures aim to improve and open the airway, making it easier to breathe.

Uvulopalatopharyngoplasty (UPPP)

Uvulopalatopharyngoplasty (UPPP) is the most common sleep surgical procedure in the world.² It can involve reshaping the muscles in the palate or removing excess tissue from the soft palate, pharynx or uvula.

In the modern approach to UPPP, surgeons tailor treatment to each person’s needs to improve results and reduce complications.² For example, if the sides of your throat tend to collapse, a lateral pharyngoplasty can be done to reshape those muscles. Alternatively, an expansion sphincter pharyngoplasty could be used to rotate a muscle to address the collapse.²⁷

Palate implants and minimally invasive options

Implants, small devices, and other minimally invasive procedures are also options. These can include:

• A pillar procedure, which uses implants to stiffen the soft palate.
• Radiofrequency ablation of the soft palate to reduce tissue volume.
• Laser-assisted uvulopalatoplasty (LAUP) for mild cases.

One study explored the effectiveness of the pillar procedure for people with sleep apnoea. In the study:⁴

• 36.7% of people experienced fewer nights of snoring.
• 73.3% reported a reduction in how loud they snored.
• 33.3% noted less daytime sleepiness.

Because no tissue is removed during this procedure, recovery is relatively quick, and individuals may experience less pain than other methods.

Radiofrequency ablation uses radio waves to shrink tissues in the airway, alleviating blockages. It can be done in a doctor’s office with local anaesthesia and may be minimally painful. Studies have found this procedure to be effective, with some research suggesting that 51% of people had a complete response at a 6-month follow-up,⁵ meaning their symptoms improved or went away completely.

During a laser-assisted uvulopalatoplasty (LAUP) procedure, a laser is used to shorten the uvula and remove excess tissue from the soft palate. Though recovery from this procedure can be quick, some research has found that it is minimally effective. One study found LAUP to only yield a cure rate of 8%.⁶

Tongue-based procedures

Another area of focus for obstructive sleep apnoea (OSA) surgeries is the tongue. If the tongue is too large or positioned in a particular way, it can block the airway when someone is lying down. These procedures aim to correct that.

Tongue reduction techniques

Multiple options are available for reducing the size of the tongue, including²⁸:

• Radiofrequency ablation, which uses radio waves to shrink the tissue at the base of the tongue.
• Transoral robotic surgery (TORS), which uses a robot arm to assist in accessing and treating hard-to-reach tissues in the back of the throat.
• Midline glossectomy, which reduces the volume of the tongue by removing tissue using a special tool called a plasma wand.

Tongue advancement and stabilisation

Rather than reducing the size of the tongue, the following procedures focus on positioning it to prevent blockages.

• Genioglossus advancement to reposition the tongue base, where the muscle attached to the lower jaw is pulled forward to reduce the likelihood of tongue collapse during sleep.²⁹
• Hyoid suspension, which uses two small screws inserted into the jaw and a suture inserted into the hyoid bone (a small U-shaped bone in the front of the neck, between the chin and the Adam’s apple) to stabilise the airway and pull the jaw forward.⁷
• Tongue suspension procedures using sutures or implants to prevent the tongue from falling backward and blocking the airway during sleep.³⁰
• Combination approaches for blockages in multiple areas of the airway.

Skeletal procedures

Skeletal procedures focus on the jaw and other bones in the face to treat obstructive sleep apnoea (OSA).

Maxillomandibular advancement (MMA)

Maxillomandibular advancement (MMA) involves moving the upper and lower jaws forward about 10 mm. On the plus side, MMA delivers high success rates. In fact, one study suggests it may reduce nighttime breathing issues by up to 83%.⁸ On the other hand, it comes with orthodontic considerations, significant facial changes and an extended recovery.

Other skeletal interventions

Other skeletal interventions include:

• Distraction osteogenesis techniques. In this procedure, a surgeon separates a bone to create space. The body then naturally fills the space with new bone as it heals. For people with OSA, this procedure can help reshape the airway and reduce breathing interruptions during sleep.
• Counterclockwise rotation of the maxillomandibular complex. Similar to the MMA procedure, this procedure moves both the upper and lower jaws forward and slightly rotates them. The adjustments help open the airway, allowing for better breathing during sleep.³¹

People with unique craniofacial abnormalities, such as a small jawbone or enlarged tongue, may need an individualised, carefully planned approach with a team of doctors to manage OSA with skeletal procedures.

Hypoglossal nerve stimulation

Hypoglossal nerve stimulation is a procedure in which a small device is implanted into the neck or chest. The device sends signals to the hypoglossal nerve, a motor nerve that controls the tongue. Doing so helps move the tongue forward during sleep, so it doesn’t block the airway.

Candidates for this procedure must be at least 18 years old and have moderate to severe sleep apnoea. They must have tried continuous positive airway pressure (CPAP) therapy and determined that it was not a good treatment for them.

Candidates also must not have complete collapse of the soft palate, which is when the soft palate and sides of throat collapse inwards.⁹ This procedure is reversible and adjustable, so it can be tailored to an individual’s needs over time.

Research has found hypoglossal nerve stimulation to be an effective option for treating obstructive sleep apnoea (OSA), significantly reducing breathing pauses in both the short- and long-term.¹⁰

Tracheostomy

A tracheostomy is a procedure that bypasses the upper airway. A surgeon creates a permanent opening into the trachea and inserts a tube into the opening. This tube enables people to breathe at night through the trachea, completely bypassing the upper airway.

A tracheostomy is generally only used for severe or life-threatening cases of sleep apnoea, or for people who have not had success with any other treatment options.¹¹ While a tracheostomy can cure OSA, it can have significant life impacts, including complications like tube displacement, weakening of the tracheal wall and infection.¹²

Considerations and treatment results

There are several factors to consider when determining whether one of these surgical procedures is right for you.

Effectiveness and success metrics

Talk to your doctor about how the success of each procedure is evaluated to better understand how well it works. In many cases, the success rates take into account the apnoea-hypopnoea index (AHI) before and after the procedure. AHI is the number of times you stop breathing per hour, and the lower your AHI, the better.¹³ For example, a person’s AHI may decrease following surgery (such as from 30 to 10), though results can vary and do not necessarily mean the condition is resolved.

Success rates vary from one procedure to another and from one patient to another. Factors that can impact the effectiveness include body mass index (BMI), age, how severe the blockage in the airway is and what part of the body is causing the blockage.

Long-term success of each of these procedures can vary. But one study found that, overall, results were positive and stable in the long run¹⁴ with less daytime sleepiness, better oxygen levels and lower AHI scores.

Risks and complications

Risks for these surgeries are procedure-specific but can include bleeding, speech changes and infection.

Procedures that require general anaesthesia have additional risks.¹⁵ General anaesthesia can be dangerous for people with obstructive sleep apnoea (OSA) because it slows down breathing and can make people more sensitive to the effects of medications used during the procedure. In these cases, an anaesthesiologist may choose certain medications over others and monitor them more closely during surgery.

Recovery expectations

Recovery time varies depending on how invasive the procedure is. For example, for a septoplasty (surgery to straighten the nasal septum), people may need 3-10 days for recovery.¹⁶ On the other hand, an MMA procedure (moving the upper and lower jaws forward slightly), may require 4-6 weeks of recovery time.¹⁷

You may need to adhere to dietary changes after your procedure. For example, you may need to follow a liquid diet or soft diet, such as smooth soups, scrambled eggs and yoghurt, in the early days of your recovery.¹⁷

When it comes to pain management, approaches may vary. In some cases, your doctor may prescribe a pain medication, or they may tell you to use an over-the-counter medication. Other pain management options can include saline sprays and rinses.

Your doctor may also request a sleep study after you heal from your procedure to determine whether it was effective. This can vary by procedure, so talk to your doctor for more information.

Special populations and considerations

• Children: Adenotonsillectomy (removing the tonsils and adenoids) has been shown to be effective for the majority of children with OSA.¹⁸
• Older adults: Being elderly (65+) is not a limitation for OSA surgeries, but older adults should talk to their doctors about the benefits versus risks.¹⁹
• People with a high BMI: People with excess body weight can face higher surgical risks, including risks with anaesthesia.²⁰
• People with craniofacial abnormalities: Those with craniofacial abnormalities (body structure difference that affect the face, jaw or skull) may be at higher risk of surgical complications, including infection and bleeding. However, some research has found that these complications have become slightly less common over time.²¹
• People with multiple comorbidities: Whether surgery for OSA is suitable for someone with multiple comorbidities depends on the individual circumstances. These people should talk to their doctors about the risks versus benefits.²²

If you’re interested in learning more about your sleep, take our sleep assessment and discuss the results with your doctor.

This blog post contains general information about medical conditions and treatments. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. The information is not advice, and should not be treated as such. You must not rely on the information on this website as an alternative to medical advice from your doctor or other professional healthcare provider.

If you have any specific questions about any medical matter, you should consult your doctor or other professional healthcare provider. If you think you may be suffering from any medical condition, you should seek immediate medical attention. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website. The views expressed on this blog and website have no relation to those of any academic, hospital, practice, or other institution with which the authors are affiliated and do not directly reflect the views of Resmed or any of its subsidiaries or affiliates.

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