Sleep Apnea Surgery

Nasal Surgery

Nasal surgeries may be recommended for people with obstructive sleep apnea (OSA) who have a deviated septum, where the wall dividing the two halves of the nose are off-center; nasal polyps, or growths in the sinuses or lining of the nose; and enlarged turbinates, which is caused by swelling of tissue structures within the nose that filter and humidify inhaled air.

While nasal surgeries may improve breathing, there's limited evidence that nasal surgeries effectively treat OSA on their own. There may be improvement, but not resolution. Instead, nasal surgeries may improve the effectiveness of other treatments such as continuous positive airway pressure (CPAP) or oral appliances.

There are many types of nasal surgeries that may be recommended for people with OSA.

• Septoplasty: In a septoplasty, a deviated septum is repaired to improve the nasal airway.
• Turbinate reduction: Swollen turbinates can occur as a result of a deviated septum or due to allergies. Reducing this tissue can help keep the airway open.
• Endoscopic sinus surgery: If nasal polyps inhibit breathing, they can be removed in a procedure called endoscopic sinus surgery.
• Rhinoplasty: A rhinoplasty can repair issues in the nose that cause breathing disruptions, including abnormalities caused by injury.
• Nasal valve surgery: The nasal valves are the narrowest portion of the nose, which limits airflow when a person breathes through their nose. Nasal valve surgery attempts to resolve obstructions originating in this area.

Mouth and Throat Surgery

Some of the most common surgeries for OSA focus on addressing physical features in the mouth and throat that contribute to a narrowed or collapsed airway.

Uvulopalatopharyngoplasty (UPPP)

Historically, one of the most common surgeries for OSA was uvulopalatopharyngoplasty. The purpose of UPPP is to keep the airway from collapsing during sleep by addressing obstructions within the upper portion of the throat, including the uvula (a small midline tissue pendulum that dangles at the back of the throat), tonsils, and a group of muscles in the roof of the back of the mouth called the soft palate.

Most people see an improvement in snoring after UPPP and about 50% experience a significant reduction in breathing issues during sleep, though a complete cure for OSA is uncommon with this procedure. Given the lack of long-term benefit, the procedure has largely fallen out of favor.

Pharyngoplasty

Pharyngoplasty describes several variants of UPPP that target specific areas of the throat that may be contributing to OSA.

• Lateral pharyngoplasty: A lateral pharyngoplasty is a surgery that involves removing the tonsils before cutting a muscle within the walls of the throat and attaching it to a muscle that runs from the tongue to the soft palate.
• Expansion sphincter pharyngoplasty: This surgery involves removal of the tonsils and part of the uvula and repositioning of several muscles in the throat.
• Transpalatal advancement pharyngoplasty: Another variation of UPPP, transpalatal advancement involves removing a portion of the hard palate to shift it forward and prevent the soft palate from collapsing and blocking the airway.

Adenoid or Tonsil Removal

Surgery to address obstructions in the upper portion of the throat often includes the removal of the adenoids, tonsils, or both. The adenoids are glands located behind the nose, while the tonsils are lower in the back of the throat. Enlarged adenoids or tonsils are associated with a greater risk for OSA, especially in children.

For children with OSA, the recommended first-line treatment is the removal of both the adenoids and tonsils during a procedure called an adenotonsillectomy. Adenotonsillectomy is among the most common surgical procedures for children in the United States. It's estimated to have an 80% cure rate for children.

Tracheostomy

For people with severe OSA and respiratory failure who don’t respond to less invasive treatments, doctors may recommend a tracheostomy. During a tracheostomy, a permanent opening is made in the neck to create an alternate airway and facilitate breathing.

Although a tracheostomy is nearly always effective in resolving OSA, this procedure changes a person’s appearance and may affect their quality of life. For these reasons, it is only rarely recommended when other treatments aren’t successful at resolving severe symptoms.

Jaw Surgery

Doctors may recommend a jaw surgery to treat OSA called maxillomandibular advancement (MMA). During this procedure, both the upper and lower jaws are shifted forward to enlarge the portion of the throat at the back of the mouth.

This surgery may be recommended for people with a jaw that is set further back and isn’t recommended for older adults or people with large necks. It may be performed as part of orthodontic management.

Tongue Surgery

During sleep, the tongue may block the airway and contribute to obstructive sleep apnea. Several procedures can reduce airway blockages caused by the tongue.

Tongue Reduction

Tongue reduction is a surgery that decreases the size of the tongue. There are several types of tongue reduction surgery. Two of the most common are:

• Midline glossectomy: Tissue from the middle of the tongue is removed
• Lingualplasty: Tissue on the sides of the tongue is removed

Tongue reductions are often performed in addition to UPPP and other surgeries to the mouth and throat. About 60% of people who have tongue reduction surgery experience improvements in nighttime breathing and daytime symptoms of OSA.

Genioglossus Advancement

The genioglossus muscle makes up the majority of the tongue’s mass and helps it move from side to side. This muscle also helps keep the airway open, so if it becomes too relaxed during sleep it may constrict or block the airway. Genioglossus advancement is a surgery that brings this muscle forward in the mouth to keep it from obstructing the airway during sleep.

Genioglossus advancement is often performed in addition to other surgeries, such as UPPP. While the success rates for this procedure vary widely between studies, one large study found that over half of people who have the procedure experience significant improvements in their nighttime breathing.

Hyoid Suspension

The hyoid bone is a U-shaped bone near the top of the throat that's attached to the underside of the tongue and nearby muscles. The hyoid plays a role in the movements and functions of the mouth and face, including keeping the airway open and supporting tongue movement. The position of the hyoid can make a person more prone to airway collapse and OSA.

Hyoid suspension is a surgery that brings the hyoid bone forward and stabilizes its position. Research shows that hyoid suspension can successfully treat OSA when performed alongside other surgeries.

Nerve Stimulation Surgeries

Nerve stimulation attempts to reduce breathing disruptions using pacemaker-like devices that are surgically implanted in the body. There are two different nerve stimulation surgeries used to treat sleep apnea. Hypoglossal nerve stimulation (HNS) is a treatment for obstructive sleep apnea. Transvenous phrenic nerve stimulation (PNS) is a treatment for central sleep apnea.

Hypoglossal Nerve Stimulation (HNS)

During this procedure, a medical device like a pacemaker is surgically implanted into the area of the chest below the collarbone. The device sends electrical currents to the hypoglossal nerve, which directs the tongue and nearby muscles. When the hypoglossal nerve is stimulated, the tongue shifts forward in the mouth and prevents it from blocking the airway.

It is used to treat moderate to severe obstructive sleep apnea when someone cannot tolerate continuous positive airway pressure (CPAP) therapy. Around 80% of people who have HNS see a decrease in the severity of their OSA, a reduction in overall sleepiness, and an improved quality of life.

Phrenic Nerve Stimulation (PNS)

Phrenic nerve stimulation (PNS) is a treatment for central sleep apnea. PNS involves implanting a medical device in the chest to stimulate the phrenic nerve which causes the diaphragm to contract. CSA is caused by a lack of signals from the brain that control breathing, so stimulating the phrenic nerve can help a person breathe more normally.

Although preliminary research shows that PNS may reduce the number of nighttime awakenings and improve daytime symptoms, there's limited research on its long-term effects and how it compares to other treatments for CSA.

Weight Loss Surgery

Weight loss surgery, also called bariatric surgery, may help improve OSA in people who have obesity and haven't found success with other weight-loss methods. Excess weight, especially around the neck and upper airway, can increase pressure on the airway during sleep, making it more likely to collapse and disrupt breathing. Enlargement of tissues within the abdomen can also collapse lung volumes leading to restriction.

Studies show that significant weight loss after surgery can reduce the severity of sleep apnea and, in some cases, lead to partial or complete symptom improvement. However, weight loss surgery doesn't cure sleep apnea for everyone, and many people still require CPAP or other treatments after surgery, particularly if apnea persists at a moderate or severe level.

Other Sleep Apnea Treatments

While there are a number of surgeries for obstructive sleep apnea, health care providers typically recommend less invasive therapies to treat sleep apnea prior to considering surgery. Common treatments for adults with sleep apnea include lifestyle changes, CPAP, BiPAP, and oral appliances.

• Lifestyle changes: Limiting the use of alcohol before bedtime, exercising regularly, and quitting smoking are all recommended strategies for improving OSA. If your OSA gets worse when you sleep on your back, your doctor might recommend transitioning to sleeping on your side or elevating the head with positional therapy.
• CPAP: CPAP is widely regarded as the most effective treatment for adults with OSA. CPAP is also a first-line treatment for the most common type of central sleep apnea. A CPAP machine delivers constant air pressure to keep the airway open during sleep.
• BiPAP: Similar to CPAP, bilevel positive airway pressure (BiPAP or BPAP) delivers pressurized air to support the airway. However, BiPAP provides air at a higher pressure during inhalation and lower pressure during exhalation.
• Oral appliances: An oral appliance is designed to shift the jaw forward and keep the airway open during sleep. Oral appliances are the most common form of OSA treatment after CPAP.

When to Talk to Your Doctor

Before considering surgery to treat sleep apnea, your doctor will likely recommend lifestyle changes, CPAP, or other therapies. If these approaches don't sufficiently treat your symptoms, or they're too difficult to maintain, your doctor may suggest surgery either alone or in combination with other sleep apnea treatments.

If your doctor recommends surgery for sleep apnea, it may be helpful to ask about the risks and benefits associated with the procedure, recovery times, and expected outcomes, as these can vary among sleep apnea surgeries.

Frequently Asked Questions

Who is a good candidate for sleep apnea surgery?

People who may be good candidates for sleep apnea surgery often include those who cannot tolerate CPAP therapy, have persistent symptoms despite treatment, or have specific anatomical features that contribute to airway blockage, such as enlarged tonsils, a narrow airway, or jaw structure abnormalities. Surgery may also be considered for children with obstructive sleep apnea caused by enlarged tonsils or adenoids.

What is the success rate of sleep apnea surgery?

The success rate for sleep apnea surgery varies widely, depending on the type of procedure and individual anatomy, with outcomes often measured by improvements in breathing events, symptoms, or reduced need for other treatments. Some procedures show moderate success while others like jaw advancement can have higher effectiveness.

Studies report a broad range of success rates for different surgical options, and success depends on factors such as the specific surgery performed and a person’s airway structure. It is recommended that a post-operative sleep study be performed to ensure resolution of the condition.

Does Medicaid cover sleep apnea surgery?

Medicaid may cover medically necessary sleep apnea surgery if documentation shows it’s needed and other treatments have been tried and failed, but coverage varies by state and specific surgical procedure. Policies differ widely, so it’s important to check with your Medicaid plan and healthcare provider to understand what's covered in your area. Prior authorization of the procedure can help to determine coverage.

How much does sleep apnea surgery cost?

The cost of sleep apnea surgery can vary significantly based on the type of procedure, location, and provider, with many common surgeries falling in a range of thousands of dollars. For example, some procedures can cost around $6,000 to $10,000, while more complex surgeries may be significantly more expensive, costing $50,000 to $100,000 or more.

Because insurance coverage and individual circumstances greatly affect out-of-pocket costs, talking with your provider and insurer ahead of time can help you estimate your expenses.