Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common and frequently occurring disease, affecting approximately 4% of men and 2% of women.
It manifests as loud snoring during sleep, with repetitive narrowing and closure of the upper airway causing respiratory disturbances, leading to hypoventilation and apnea during sleep.
This causes nocturnal hypoxia, micro-arousals, and disrupted sleep structure, resulting in daytime sleepiness and difficulty concentrating, severely impacting patients’ quality of life.
Furthermore, patients may suffer from multiple organ damage due to conditions such as hypertension, coronary heart disease, and diabetes.
Continuous positive airway pressure (CPAP) is currently the preferred treatment for moderate to severe OSAHS.
However, for patients with upper airway structural abnormalities and intolerance to CPAP therapy, upper airway reconstruction surgery is currently recommended as the primary treatment for these patients.
Based on the different sites of upper airway stenosis or obstruction, combined with clinical manifestations and polysomnography (PSG) results, individualized surgical plans are needed to treat different patient types.
Types of Sleep Apnea Surgery
Sleep apnea surgery can target several different areas of the body, any of which may be preventing you from breathing easily during sleep:
Nose
Tongue
Palate, the tissue at the back of your mouth and throat
Bone structures in your face, neck, and jaw
It should be noted that surgical treatment of sleep apnea syndrome has certain risks and complications, such as bleeding, infection, dysphagia, etc.
Therefore, before deciding on surgical treatment, patients need to undergo a comprehensive evaluation, including sleep monitoring, imaging examinations, etc., to determine the indications and contraindications for surgery.
For children with sleep apnea syndrome, surgical treatment should be undertaken with caution. Children’s maxillofacial bones and airway structures are not yet fully developed, and the effectiveness and safety of surgical treatment may not be as good as those in adults.
1.Tracheal Surgery
Tracheotomy is a temporary treatment for severe sleep apnea. It offers three main benefits: it improves the patient’s oxygen deprivation before surgery, improving their physical condition and making them more resilient to the procedure; it ensures safe breathing during anesthesia; and it facilitates airway management after surgery, reducing risks.
While it can completely relieve the patient’s obstructive symptoms and improve sleep, tracheotomy can easily lead to infections around the incision and in the lower respiratory tract, and can cause inconvenience and psychological burden to the patient.
Therefore, it is currently reserved for patients with severe OSAHS who are comatose, have cor pulmonale, heart failure, or have arrhythmias.
For these patients, tracheotomy remains irreplaceable to relieve life-threatening asphyxiation caused by upper airway obstruction. Permanent tracheotomy is a life-saving procedure for patients with extremely severe OSAHS.
Current standard treatment consists of three steps:
Preoperatively, the patient sleeps on a non-invasive ventilator for a week to correct hypoxia and optimize their body’s tolerance for surgery.
During surgery: While under anesthesia, the doctor inserts a tube through the patient’s nostrils to maintain breathing.
Postoperatively, The tube is not removed immediately but remains in place for one to three days, depending on the patient’s condition, until the airway stabilizes. This method is highly effective, eliminating the need for a more invasive tracheotomy.
2.Nasal Surgery
Nasal expansion surgery is currently an important treatment for OSAHS. It reduces or relieves patients’ nasal congestion symptoms by correcting abnormal nasal structures such as nasal septum deviation and lateral nasal wall variation, expanding ventilation volume, and restoring bilateral ventilation symmetry.
Another benefit is that once the nose is unobstructed, patients can better adapt to the CPAP machine, which reduces resistance to treatment and helps with long-term adherence. Common surgeries include: turbinate surgery, nasal septum surgery, nasal polypectomy, and nasal valve reconstruction.
With the development of minimally invasive surgical technology, surgery has gradually tended to be minimally invasive procedures such as submucosal resection of the nasal concha, lateral fixation of the turbinate, low-temperature radiofrequency treatment of the turbinate, submucosal correction of the nasal septum, suction-removal nasal polyp surgery, and partial resection of the greater alar cartilage.
Approximately 44% of patients with sleep apnea have stenosis within their noses, which acts like a narrowing of a road, resulting in significantly greater airflow resistance than normal.
For this reason, doctors use a specialized “airflow monitoring” technique to analyze how the internal structure of the nose affects breathing.
This analysis provides precise guidance for surgical procedures: first, it helps determine whether surgery is essential; and second, if surgery is needed, it can accurately determine which tissues and how much should be removed to achieve the best therapeutic outcome.
Nasal expansion surgery can improve simple snoring caused by nasal obstruction and snoring symptoms in patients with mild OSAHS, but it has no significant improvement in patients with moderate to severe OSAHS.
However, it is still an important part of OSAHS treatment, which can especially help patients be more willing to adhere to the use of ventilators, thereby improving treatment outcomes.
3.Palate Surgery
3.1 Uvulopalatopharyngoplasty (UPPP)
In layman’s terms, a classic surgical procedure for treating snoring and apnea (UPPP) involves trimming excess tissue at the back of the throat (such as the uvula and soft palate) to open up the respiratory passages.
However, traditional procedures involve removing the uvula, which can lead to complications such as nasal speech and choking when drinking water.
Doctors have since refined their technique: they now preserve the uvula as much as possible, meticulously removing only the excess fatty tissue behind it.
This approach widens the throat while minimizing damage to the throat’s original anatomy, significantly reducing postoperative complications.
For more complex cases (such as those who have already had tonsillectomy), there’s also the “Z-shaped pharyngeal stenosis” (ZPP). This procedure splits the uvula in half and sutures the soft palate upwards, like a curtain.
This not only widens the throat anteriorly but also laterally. During healing, the scar further pulls on the tissue, widening the throat even further. Because muscle function is preserved, permanent closure is virtually nonexistent. This procedure has a significantly higher success rate (68%) than traditional methods (28%).
Combining ZPP with other procedures, such as tonsillectomy, creates the “Z-shaped pharyngeal stenosis” (ZPPP), a procedure used to treat severe pharyngeal stenosis with a success rate of 64.7%.
3.2 Soft Palate Advancement Surgery
This procedure aims to widen the nasopharynx, the passage at the back of the nasal cavity. The key principle is to remove a small section of the back edge of the hard palate (the bony part of the upper jaw), thereby creating space for the soft palate (the soft part behind the hard palate) to be lifted forward and upward, ultimately widening the airway.
The main surgical steps can be summarized as follows:
1. Incision and Exposure: The surgeon makes a specially shaped incision at the back of the maxillary palate (avoiding major blood vessels). The surgeon then carefully separates the mucosal tissue, like pulling back a rug, to expose the underlying hard palate bone plate.
2. Osteotomy and Lift: Next, approximately 1 cm of bone is removed from the posterior edge of the hard palate. This allows the soft palate and palatine aponeurosis, previously attached to the posterior edge of the hard palate, to move forward.
3. Fixation and Enlargement: Finally, the entire soft palate is pulled forward and reattached to the shortened hard palate edge. This process, like “shortening the drawstring on a curtain,” prevents the soft palate from collapsing posteriorly, significantly widening the airway in the nasopharynx.
This procedure can often be performed concurrently with a classic uvulopalatopharyngoplasty (UPPP) procedure, thereby widening the airway from the nasopharynx to the oropharynx.
Hard palate shortening and soft palate advancement is a delicate procedure used to widen the upper airway. Its core principle is to remove a small section of the posterior edge of the hard palate (the bony part of the upper dentition) to create space for the soft palate (the soft part of the uvula) to be lifted and lifted forward.
The main advantage of this procedure is that it effectively strengthens the supporting tissues on both sides of the nasopharynx, preventing the soft palate from collapsing during inspiration, while maintaining minimal impact on facial appearance.
It is particularly suitable for patients with obstruction caused by an excessively long hard palate, narrow nasopharyngeal bone structure, or those who have not responded well to traditional UPPP. The success rate of this procedure is approximately 67%-68.8%.
When performed in conjunction with UPPP, it addresses both bony and soft tissue obstruction, significantly improving overall treatment effectiveness.
4.Tongue Surgery
4.1 Tongue body and tongue base volume reduction surgery
This procedure is primarily used to treat sleep apnea caused by excessive tongue hypertrophy. Its core principle is to safely remove a portion of the enlarged tongue tissue, while ensuring that essential tongue functions (such as speaking and swallowing) are not compromised, thereby creating more space in the throat.
However, due to the presence of important motor nerves on both sides of the tongue, extensive resection is difficult to perform to avoid damage. Therefore, it is often used as an adjunct to comprehensive treatment.
Clinical studies have differed regarding the safe extent of resection, but currently, more conservative standards (such as 7 mm lateral to the midline and 10 mm deep) are generally recommended for maximum safety.
There are various surgical methods, including cryo-radiofrequency resection and wedge resection. Importantly, the tongue will swell significantly after surgery, posing a high risk of airway obstruction. Therefore, strict airway management is essential, and intubation or pre-operative tracheotomy is often necessary to safely manage the swelling.
4.2 Lingual Tonsillectomy
Enlarged tonsils at the base of the tongue are a common cause of pharyngeal stenosis. Current surgical treatments include laser, microwave, and radiofrequency ablation, as well as a method called spatula removal.
However, even with rigorous selection, some patients still experience suboptimal outcomes and require a more thorough “lingual tonsil snare” procedure. If this procedure is performed under local anesthesia, patients often struggle to cooperate due to fear, nausea, or pain, making the procedure more difficult.
In contrast, performing this procedure under general anesthesia offers significant advantages: simpler instruments, easier operation, and minimal damage to surrounding tissue. This effectively avoids accidental injury and allows for a cleaner excision of tissue, minimizing residual tissue.
The key to the procedure lies in the surgeon’s precise dissection within the natural gap between the lingual tonsil capsule and the tongue muscles, thereby maximizing muscle protection and ensuring surgical safety.
4.3 Frenglossus advancement and hyoid bone suspension
Imaging studies have shown that in many patients with OSAHS, the hyoid bone (a small, U-shaped bone located above the larynx) is positioned lower and further back than normal, resulting in narrowing of the lower throat.
Hyoid suspension surgery surgically lifts the hyoid bone forward and upward to widen this portion of the airway, thereby treating respiratory obstruction.
Therefore, this procedure is a crucial treatment option for moderate to severe cases, particularly those with obstruction at the base of the tongue.
The basic principle of the surgery is to partially sever the neck muscles that pull the hyoid bone downward and then move a portion of the chin tip forward, along with the two muscles attached to it that lift the hyoid bone upward (genioglossus and geniohyoid muscles). These muscles then “suspend” the hyoid bone in a more forward position.
Key considerations include delicate manipulation during surgery to protect the tooth roots, and because the mid-chin structure is relatively fragile, a custom titanium plate is required for secure fixation after surgery, along with a dental arch splint for 4-6 weeks. A soft diet is recommended during this period to prevent fractures.
Traditional slinging techniques primarily rely on two relatively weak muscles for suspension, resulting in limited effectiveness. Now, through the same surgical incision, additional, more powerful muscles (such as the digastric muscle) can be incorporated into the slinging system, significantly enhancing the lifting effect.
Academia is divided on the reasons for the effectiveness of this procedure. Some believe it is due to the horizontal advancement of the hyoid bone, directly widening the airway space; others find that the increase in space is limited (approximately 3 mm).
Its primary effect may be to prevent the tongue from falling back during sleep by increasing muscle tone. Others believe the procedure primarily improves the “functional” collapse of the airway during sleep, rather than simply altering its static dimensions.
5. Bimandibular Advancement Surgery
Bimaxillary advancement surgery is a surgical procedure that simultaneously advances the maxillary and mandibular bones (i.e., the entire gums) to significantly widen the airway in the throat.
It is primarily indicated for patients with a receding mid- and lower-face area (small chin) and severe obstructive sleep apnea (OSAHS).
Surgical Principle and Procedure
This procedure involves moving the entire mid- and lower facial skeleton forward, thereby retracting the attached soft palate and tongue base, ultimately relieving obstruction in the laryngopharynx and tongue base planes. The standard procedure involves two core steps:
Maxillary advancement: The maxillary bone is resected at a specific location, moved forward as a whole, and secured with a titanium plate.
Mandibular advancement: The mandibular ramus is resected, and the main mandible with the teeth is moved forward also securely secured.
Efficacy and Features
This surgery is currently one of the most effective treatments for severe OSAHS, with an extremely high success rate (95%-100%), second only to tracheotomy in effectiveness.
However, due to its high invasiveness, technical requirements, and significant alteration of facial contours, it may cause bite problems. It is usually used as a last resort after other surgical procedures have failed. Depending on the patient’s specific situation, doctors may choose to advance only the maxilla or mandible.
6. Distraction Osteogenesis
Distraction osteogenesis is an advanced bone lengthening technique. It works by slowly and continuously applying distraction to stimulate the body’s natural bone growth mechanism, allowing new bone to naturally grow within the fractured bone.
This technique offers advantages such as minimal trauma, a low recurrence rate, and the ability to simultaneously lengthen both bone and surrounding soft tissue.
For patients with sleep apnea caused by mandibular retrusion (small chin), it can effectively widen the narrowed pharyngeal airway by advancing the mandible, significantly improving nighttime breathing and sleep quality.
The treatment process is generally as follows:
Approximately seven days after surgery, the distraction device will be adjusted to slowly lengthen the jaw at a rate of approximately 1 mm per day, reaching a maximum advancement distance of 25 mm.
During this period, sleep monitoring will be performed regularly to ensure that breathing disturbances have resolved. Once the ideal position is achieved, the distraction device is immobilized for 2-3 months to allow for new bone maturation, after which the distraction device can be removed.
To maintain the effect and prevent retraction, internal fixation with a small titanium plate is often performed upon removal.
For complex cases with severe mandibular underdevelopment, doctors may also utilize multi-site or simultaneous maxillary and mandibular distraction, a proven and reliable technique with an extremely high success rate.
Can Surgery Cure Sleep Apnea?
Whether obstructive sleep apnea (OSA) can be cured surgically depends on the cause, severity, and surgical approach.
For some patients (such as those with obstructive sleep apnea clearly caused by enlarged tonsils, nasal polyps, or maxillofacial structural abnormalities), surgery can significantly improve or even eliminate symptoms.
However, in most cases, surgery is an adjunct to symptom improvement rather than a complete cure, requiring postoperative management and long-term follow-up.
Can surgery "cure" the condition completely?
1. Some patients can achieve a clinical cure:
If the cause is clear and the surgery can address it specifically (such as adenoids/tonsillectomy in children, correction of severe nasal septal deviation), symptoms may completely disappear after surgery.
2. Most patients experience improvement rather than a cure:
Adult obstructive sleep apnea is often caused by multiple stenosis or obesity. Single surgeries (such as uvulopalatopharyngoplasty) only address localized issues and require comprehensive treatment, including weight loss and mechanical ventilation.
3. Surgery has limited effectiveness in severe cases:
Severe OSA patients have extensive airway collapse and may still require mechanical ventilation after surgery, resulting in a high recurrence rate.
Key Factors Affecting Surgical Outcome
1. Etiology and Classification:
Central sleep apnea (CSA) is typically not treated surgically.
Obstructive sleep apnea (OSA) requires identification of the site of stenosis (nasal cavity, pharynx, tongue base, etc.).
2. Patient Individual Conditions:
Obesity (BMI ≥ 32), maxillofacial skeletal abnormalities, and older age may limit surgical outcomes.
Preoperative evaluation requires precise evaluation using polysomnography, videolaryngoscopy, and imaging.
Conclusion
Surgery is an effective treatment for certain types of OSA, but it is not a panacea. A specialist should assess the cause, develop a personalized plan, and implement long-term health management.
For those who are unable to undergo surgery or whose condition is ineffective, mechanical ventilation remains the most reliable treatment. CPAP is the first-line treatment for OSA, and surgery should only be considered when conservative treatment is ineffective and anatomic abnormalities are clearly identified.
Approximately 30% of patients experience a recurrence of symptoms five years after surgery, necessitating regular sleep monitoring.
