While it is difficult to estimate an exact number, about two in 10 Americans suffer from obstructive sleep apnea (OSA), a condition characterized by episodic obstruction of the airway during sleep. Some individuals who suffer from OSA have daytime sleepiness, decreased sleep quality, and increased cardiovascular risk. The disease imposes a strong impact on the patient's health and a significant reduction in quality of life.
Treatment of OSA is challenging, mostly because the disease varies substantially from patient to patient. Numerous factors contribute to this variability, such as the patient's age and weight, components of the sleep itself such as the sleep architecture and amount of sleep needed, and the overall severity of the airway obstruction. Our goal is to identify these complexities and determine which treatment will be most beneficial to each patient.
Once we establish the diagnosis of OSA, we provide the patient with all available information to involve him or her actively in the decision to select the most adequate treatment. This is particularly important in this condition since OSA is a chronic problem that requires long-term management. Behavioral measures such as weight loss (when required) and avoidance of alcohol and sedatives before bedtime are an important part of treatment and almost always result in some improvement.
The treatment of choice for OSA is continuous positive airway pressure (CPAP), a device that delivers pressurized air through a fitted mask to maintain the upper airway open. For most patients, CPAP is very effective, but some refuse this option and others cannot tolerate it, requiring an alternative treatment. Some of these patients may have an anatomic abnormality in the upper airway that potentially may be corrected. For them, surgery can be an alternative.
Many patients, family members, and even physicians are skeptical and question the efficacy of surgery to treat OSA. This uncertainty arises from somewhat low success rates associated with uvulopalatopharyngoplasty (UPPP), the most commonly performed surgical procedure for OSA in the U.S. In this procedure, the surgery targets only the soft palate, without improving potential collapses in other areas of the upper airway. However, recent developments in this field -- in great part pioneered at Stanford University by Drs. Nelson Powell and Robert Riley -- provide the opportunity for more complex techniques to evaluate the upper airway and to treat obstructions at sites other than the palate. These cutting-edge approaches maximize airway improvement by reducing the anatomical obstruction or decreasing the collapse of tissue causing the obstruction in the nose, throat, or tongue -- or, which is more common, in all of these sites. Currently, these procedures are offered by a limited number of surgeons in the country.
It is fundamental to identify those patients in whom surgery will work best and what are the ultimate treatment goals for them. In some cases, surgery can offer a definitive solution for OSA. In others, it can be part of a comprehensive approach to target the problem with success, improving to some degree the severity of the airway obstruction and allowing the use of additional measures such as avoidance of back sleeping or the combined use of an oral appliance to reduce the impact of the disease.
The results of the surgery may be less pronounced in older adults and obese individuals, although some of these patients still benefit from surgery which helps make the use of CPAP more tolerable, particularly if nasal obstruction is an associated problem.
To answer the question if surgery really works for sleep apnea, we can say that if the goal is to decrease the cardiovascular risk associated with OSA and improve the symptoms associated with the disease such as daytime sleepiness, snoring severity, and poor sleep quality, there is convincing evidence showing good results for each one of these problems. There is also a substantial amount of data suggesting improvement in quality of life and, very gratifying for the treating surgeon, frequent restoration of a more harmonious bedtime routine with loved ones.
Dr. Robson Capasso is currently the Director of Sleep Surgery and Assistant Professor of Otolaryngology and Head and Neck Surgery at Stanford University School of Medicine. His quite extensive and unique training includes otolaryngology and fellowships in head and neck and microvascular surgery, neurosciences, and sleep medicine. Dr. Capasso has published and reviewed book chapters, articles, and original papers in peer-reviewed journals. He has been an investigator on imaging modalities and treatment evaluation of obstructive sleep apnea patients. The global recognition of his work is often associated with one of his favorite tasks: lecturing and trading knowledge around the world. He also works at the Stanford Center for Sleep Sciences and Medicine. This center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades. To learn more, visit us at: http://sleep.stanford.edu/.
Sources:
Caples, SM et al. "Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis." Sleep. 2010. 33(10):1396-407.
Holty, JE and Guilleminault, C. "Surgical options for the treatment of obstructive sleep apnea." Med Clin North Am. 2010. 94(3):479-515.
Peker, Y, Hedner, J, Norum, J, Kraiczi, H, Carlson, J. "Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up." Am J Respir Crit Care Med. 2002 Jul 15;166(2):159-65.
Shen, T, Shimahara, E, Cheng, J, and Capasso, R. "Sleep medicine clinical and surgical training during otolaryngology residency: a national survey of otolaryngology residency programs." Otolaryngol Head Neck Surg. 2011 Dec;145(6):1043-8.
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