Obstructive Sleep Apnea

Surgical Approaches to Obstructive Sleep Apnea

Daniel A. Larson, MD

Southwest Ohio ENT Specialists

Obstructive Sleep Apnea (OSA)

Part of the Sleep Related Breathing Disorder (SRBD) Continuum.


  • Prevalence of 4% for women and 9% for men in US, though some studies suggest this is much higher.
    – M:F ratio of 2-3:1 (evens out post-menopause)
    – 80 – 92% is undiagnosed
  • Increased Prevalence with age >65yo

Pathophysiology of OSA

  • Excess external pressure
    a. e.g. In obese pts
  • Anatomic narrowing
    a. Bernoulli effect
  • Decreased rigidity
    a. Lower NM tone


Symptoms of OSA

Nocturnal symptoms:

  • Snoring, usually loud, habitual
  • Witnessed apneas, which often interrupt the snoring
  • Nocturia (esp. in peds)
  • Insomnia
  • Restless sleep, with patients often experiencing frequent arousals

Daytime symptoms:

  • Morning headache, dry or sore throat
  • Excessive daytime sleepiness (EDS) that usually begins during quiet activities
  • Cognitive deficits; memory and intellectual impairment
  • Personality and mood changes, including depression and anxiety
  • Sexual dysfunction, including impotence and decreased libido
  • GERD

Physical Exam

  • Obesity – Body mass index (BMI) greater than 30 kg/m2
  • Large neck circumference – Greater than 43 cm (17 in) in men and 37 cm (15 in) in women
  • Abnormal (increased) Mallampati score
  • Narrowing of the lateral airway walls
    i. independent predictor of the presence of OSA in men but not women
  • Enlarged (ie, “kissing”) tonsils (3+ to 4+)
  • Small mandible

Lateral narrowing


  • Diagnosis
    1. Home vs. Lab
  • Mild = AHI 5-15
  • Moderate = AHI 15 – 30
  • Severe = AHI > 30

Treatment (peds)

  • T&A
  • Curative in 80% of pts
    1. Less effective in
      • obese pts
      • African American
      • Higher AHI
      • Small tonsils
      • Teens
  • Consider DISE in pts with persistent OSA vs. CPAP

Treatment (adults)

  • Mild OSA
    • Behavioral modification
    • Weight loss
    • positioning
  • Mild to Moderate
    • Option for mandibular advancement splint
  • Mild to Severe
    • CPAP
      • Nasal pillows—> nasal mask—–>full face
    • BiPAP

Failure to tolerate PAP therapy…….

Surgical Candidacy (general)

  • Failure to tolerate CPAP in any severity of OSA
    • Claustrophobia, mask irritation, tubing issues, nasal obstruction
  • Refusal to use CPAP
  • Mild to Moderate OSA with a discrete source of obstruction

Considerations for OSA Surgery

  • In General (historically) Surgery is high morbidity with low return
  • Pt selection is key
  • Set realistic expectations for patients (esp. overweight)
  • Goals of Surgery
    • Adjunct to non-surgical therapy
    • Salvage Therapy for non-surgical failures.


Surgical Decision making

  • Severity of disease
    • AHI and disease burden
  • Patient goals
  • Age
  • Pattern of airway collapse

Role of Nasal Surgery

  • Good option for snoring and UARS patients
  • Typically, will not cure OSA
    • Improve CPAP tolerance
    • As part of multilevel surgery – improved outcomes
    • Improve sleep related Quality of Life
      • Decreases sleep fragmentation, daytime sleepiness

Why improvement with nasal surgery?

Common sequence of obstruction

  • Nasal obstruction
  • Leads to mouth breathing
    • Open mouth posture
  • Tongue falls back
  • Leads to obstruction at the base of tongue

Role of nasal surgery

– Surgical Success rate in nasal surgery group was 68% compared to 55% in no nasal surgery group (P=.002).
– Nasal surgery alone does not significantly affect AHI, ESS.

Uvulopalatopharyngoplasty (UPPP)


Friedman scale for pt selectio

UPPP modifications

Expansion sphincter pharyngoplasty (lateral expansion pharyngoplasty)
– Good for stabilization of the lateralOP wall

Hypoglossal Nerve Stimulator (HGNS)

HGNS Patient Selection

– AHI 15-65
– BMI <32 kg/m2
– Failure to tolerate CPAP
– <25% central apneas – Age >18
– No source of fixed upper airway obstruction (eg severe ATH, mass, etc.)


– > 25% central apneas
– Concentric collapse of the velopharynx
– Any physical finding that would compromise the performance of UAS
– Any condition that has compromised neurologic control of the UA
– Pt who cannot operate remote w or w/o assistance.
– Pregnant
– Other implants that may interact with UAS
– Pts who require MRI of the chest
– Safe for all other MRIs

STAR trial – outcomes

Future Directions

  • Bilateral HGNS
    • Via transcutaneous stimulation
    • Currently being trialed in Europe

Eastwood, PR et al. Bilateral HGNS in Adults with OSA. European Resp J. 2020


Daniel Larson
www.soents.comPhone: (937)496-2600

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