gms | German Medical Science

Many patients with obstructive sleep apnea (OSA) cannot accept nasal ventilation therapy for various reasons. Compliance rates range from 60–80%. Those patients require alternative treatment such as positional therapy, mandibular advancement devices or surgery. Surgery has to be evaluated according to the criteria of evidence based medicine. However, each surgical procedure as well as surgical concepts and algorithms, respectively, have to be looked at separately. Nevertheless, there are more and more studies published with increasing levels of evidence

Minimally invasive surgery such as interstitial radiofrequency (RF) treatment and palatal implants are primarily indicated in snoring and mild OSA. Treatment success with either technique can be achieved in 30–50% of the patients in case series. Interstitial RF treatment of the palate has been proven superior to placebo treatment in snorers as well as palatal implants in mild OSA. However, complete elimination of snoring is rare with interstitial treatment alone due to redundant palatal mucosa which needs to be resected using RF cutting devices, hence increasing success but also pain in snorers. Minimally invasive surgery can serve as first line treatment in thoroughly selected patients due to their minimal morbidity.

Patients with moderate OSA are offered surgical therapy only after CPAP failure or incompliance. UPPP remains the standard procedure with success rates of approximately 50% shown in case series of 10 year follow-up. Additional tonsillectomy doubles the success rate of UPPP from 30 to 60%. There have been various modifications of UPPP such as uvuIaflap, expansion sphincteroplasty, or lateral pharyngoplasty which are useful for certain anatomical findings. If the intertonsillar distance is below 5 mm then the success rate of solitary tonsillectomy is above 80%. The need of additional diagnostic workup of the pharynx by videoendoscopy under sedation or pharyngo-esophageal manometry is still discussed controversially.

Multilevel surgery combining a palatal with a retrolingual procedure is the standard treatment in moderate to severe OSA addressing the entire upper airway. Even though controlled trials are lacking case series present with success rates of 54% in more than 1500 patients. Although morbidity (pain and dysphagia) is relevant and can be long-lasting, more than 90% of the patients are satisfied with this type of surgery.

Tracheotomy as a bypass of the upper airway has become the last resort treatment due to its morbidity and social stigma regardless its efficacy in almost every patient.

Maxillomandibular surgery in skeletal deficiency as well as bariatric surgery in obesity are have to be considered as very successful surgical options performed by other surgical disciplines addressing the underlying etiology in some patients.

ENT-surgeons have the best knowledge of the upper airway and are suitable best to decide upon alternative treatment options in cases of CPAP-incompliance or in mild OSA and snoring.