Sleep Apnea Surgery: Overview

Obstructive sleep apnea (OSA) surgery involves the reduction or removal of a blockage in a patient's upper airway (nose, tongue, or throat) that is resulting in brief stops in breathing during sleep. There are several procedure options, all of which are generally considered when continuous positive airway pressure (CPAP) or an oral appliance can't be tolerated or their effects need to be improved or enhanced.

OSA is a serious medical condition that can result not only in daytime fatigue, but chronic health issues like hypertension, diabetes, and more. Sleep apnea surgery may be the solution for reducing these risks, and knowing what's involved can help you feel more prepared if this procedure is recommended for you.

What Is Sleep Apnea Surgery?

OSA is caused by upper airway anatomic abnormalities like an oversized tongue, enlarged tonsils, a small jaw, or a deformed nasal septum, to name a few. Fat deposits in the upper airway from obesity can also cause or contribute to OSA.

There are several different types of sleep apnea surgeries, each one targeting a specific area of airway obstruction, such as the tonsils, soft palate, tongue, nose, or throat. By removing or reconstructing tissue or bone, the surgeon creates a larger, more stable airway for the patient. If you have multiple areas of obstruction, a combination of surgeries—performed in stages or during the same operation—may be indicated.

It's important to note that you may still have to use your CPAP or oral appliance after surgery. In these cases, surgery is not curative but rather performed to enable you to better use and succeed with your prior (and more preferred) sleep apnea therapy.

Sleep apnea surgery is typically performed in an ENT (ear, nose, and throat) clinic procedure room or in an operating room in a hospital under local or general anesthesia.

The vast majority of surgeries are scheduled and can be done in adults, adolescents, or children. Depending on the surgery, it may be performed on an inpatient or outpatient basis.

Types

When selecting the right procedure, your surgeon will take into account several factors, such as your anatomy, overall health, personal preferences and expectations, and OSA severity.

The different types of sleep apnea surgeries include:

• Uvulopalatopharyngoplasty (UPPP): Removal of excess tissue in the upper airways, including the tonsils, uvula, and/or the soft and hard palate (this is one of the most common sleep apnea surgeries performed)
• Tonsillectomy: Removal of the tonsils
• Adenoidectomy: Removal of the adenoids
• Septoplasty: Correcting a deviated nasal septum
• Turbinate reduction: Reducing the size of the turbinates (shell-shaped structures located inside your nose)
• Midline glossectomy and lingualplasty: Removal of part of the back of the tongue
• Genioglossus advancement: Moving the major tongue muscle attachment forward by making a cut in the lower jaw
• Hyoid suspension: Pulling the hyoid bone (a U-shaped bone located in the back of the throat) forward and securing it in place
• Radiofrequency volumetric tissue reduction (RFVTR): Shrinking and tightening tissue from the uvula, soft palate, tongue, tonsils, and/or turbinates using heat
• Maxillomandibular advancement (MMA): Moving the lower part of your face (teeth, upper jaw, lower jaw, and associated soft tissues) forward in order to create a larger space for breathing
• Laser-assisted uvuloplasty (LAUP): Partially removing the soft palate and uvula using a laser (this procedure has fallen out of favor due to associated complications and decreased effectiveness)

Besides removing or reconstructing parts of the airway, a surgeon may implant devices within the mouth to reduce airway collapse and treat sleep apnea.

Two such procedures include:

• Palatal implants: Implanting small semi-rigid rods into the soft palate
• Inspire hypoglossal nerve stimulator placement: Implanting a tongue pacemaker that contracts muscles of the tongue and upper airway

Another surgery, called a tracheostomy, may be performed in patients with severe sleep apnea who have failed to improve with other medical and surgical treatments. In this surgery, a hollow tube is placed through a hole made in the windpipe (trachea). While highly effective, this is a drastic, life-changing surgery and, therefore, reserved as a last resort.

Bariatric surgery, like Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy, usually reverses or at least significantly improves sleep apnea and may also be considered. However, weight loss surgery is not indicated for a diagnosis of OSA alone.

Surgical Techniques

To optimize the effectiveness and safety of a sleep apnea surgery, surgeons are constantly tweaking and refining their techniques. For example, techniques for performing UPPP have evolved to include less resection (cutting and removal of tissues) and more reconstruction.

These newer techniques are associated with fewer side effects, both short-term and long-term, and improved CPAP tolerance.

Contraindications

While contraindications for sleep apnea surgery vary based on the nature of the procedure, some general ones include:

• A problem that cannot be surgically corrected
• Poor physical health
• Active infection
• Bleeding disorders
• Unrealistic expectations

Potential Risks

Patients with OSA are at a higher risk for bleeding, infection, blood clots, and complications related to general anesthesia when undergoing any surgery.

Other risks vary based on the specific procedure being performed.

For example, risks associated with UPPP include:

• Severe, short-lived throat pain
• Long-term pain with swallowing (chronic dysphagia)
• Coughing at meals
• Nasal regurgitation (when liquid come up through your nose when drinking)
• Speech changes
• Dehydration

Risks associated with a midline glossectomy and lingualplasty include:

• Pain
• Bleeding
• Tongue infection
• Taste change
• Dysphagia
• Tongue paralysis

Risks associated with an MMA procedure include:

• Damage to the teeth
• Lower jaw fracture
• Facial numbness
• Blockage of one side of the nose
• Temporomandibular joint (TMJ) problems
• Palatal necrosis (tissue death)

Purpose of Sleep Apnea Surgery

Sleep apnea surgery is done to cure or at least reduce episodes and effects of obstructive sleep apnea.

While CPAP and oral appliances—more common and conservative options—are very effective sleep apnea treatments in many cases, some find them uncomfortable and obtrusive. Regular CPAP maintenance is also required to keep the equipment clean, which some have a hard time committing to.

Any treatment can only be as good as a patient's adherence to it, so surgery may be considered if compliance is a concern. Surgery may also be used to improve a patient's use of CPAP/oral appliance.

If a procedure is being considered, you would have already had a home sleep apnea test (HSAT) or an in-center diagnostic polysomnogram (sleep study) to confirm your obstructive sleep apnea diagnosis.

Several other tests and evaluations need to then be done to determine whether you are an appropriate surgical candidate and to help the surgical team select the right procedure(s) for you.

Examples include:

• Assessment of OSA symptoms, signs, and severity, including recent sleep studies and treatment experiences (e.g., CPAP, oral appliances, and/or weight loss)
• Assessment of potential airway management problems during surgery/anesthesia administration (e.g., length and range of motion of neck, size of the tongue and teeth, and presence of any neck bone deformity)
• Evaluation for medical conditions associated with OSA (e.g., hypertension, diabetes, obesity hypoventilation syndrome)
• Upper airway imaging tests, like computed tomography (CT)
• Echocardiogram if there is a suspicion for severe pulmonary hypertension
• Consultation with a cardiologist for patients with heart disease or significant cardiac risk
• Routine pre-operative tests including an electrocardiogram (ECG) and blood tests (e.g., complete blood count and basic metabolic panel)

How to Prepare

To prepare for your sleep apnea surgery, you may be instructed on the following:

• Stop smoking at least four weeks leading up to surgery
• Stop taking certain medications and drinking alcohol for a designated period of time.
• Avoid eating or drinking 12 hours prior to your surgery.
• Arrange for someone to drive you home after the procedure or after your hospital stay, as applicable.
• Bring loose-fitting, comfortable clothing to wear when leaving the hospital or surgical center.

What to Expect on the Day of Surgery

Depending on the type(s) of procedure being performed, the operation time for a sleep apnea surgery can be anywhere from 45 minutes to several hours.

Some surgical procedures, like a UPPP or MMA, require an overnight hospital stay. With other procedures, like a hyoid suspension or nasal surgery, you can go home after your procedure.

While the precise steps of your surgery will depend on the type of procedure you are having, here's a general sense of what you can expect after you are prepped for surgery (your vitals are taken, your IV is placed, etc.):

• Anesthesia administration: With general anesthesia, an anesthesiologist will give you medications to render you temporarily unconscious. Once you are asleep, an endotracheal (breathing) tube will be placed. With local anesthesia, you will be given a sedating medication to help you fall into a light sleep followed by a medication that numbs the area to be operated on.
• Visualization: The part of the airway being operated on (e.g., nasal passage, throat, or tongue) will be exposed, often with the use of retractor instruments, so that the surgeon can see it.
• Reconstruction: The surgeon will use surgical instruments to reduce, remove, or reposition tissues/bones to open up the airway.
• Stabilization: The surgeon may use stitches, splints, titanium plates, or screws to secure tissue/bone in its new position.

After anesthesia is stopped and the breathing tube is removed, if applicable, you are transferred to a recovery room to wake up.

Recovery

After waking up in the recovery room, you may experience soreness in your mouth, throat, and/or nose. A nurse will give you pain medication through your IV and monitor your vital signs (e.g., blood pressure, heart rate, and oxygen level).

Depending on the procedure you underwent, you may be discharged home from the recovery room or taken to a hospital room for an overnight stay. As an example, a UPPP requires an overnight stay while jaw surgery requires a multiple-night hospital stay. On the other hand, patients undergoing nasal procedures or a hyoid suspension can usually go home the same day.

Specific recovery instructions and timelines also vary based on the surgery performed. For example, recovery from surgeries performed on the throat, tonsils, soft palate, uvula, or tongue (e.g., UPPP or tonsillectomy) takes around two weeks.

During this time, your surgeon will likely advise you to:

• Drink fluids to prevent dehydration and keep the mouth and throat moist
• Take liquid pain medicine 20 to 30 minutes prior to eating
• Eat a soft diet to prevent irritation and bleeding of the surgical site
• Rinse your mouth after eating with a salt-water solution
• Avoid heavy lifting and strenuous exercise for two weeks

Recovery from a jaw surgery like MMA tends to take longer and be a bit more extensive. Example post-operative instructions may include:

• Adhere to a liquid diet for 10 to 14 days (your jaw may be wired shut or held in place with elastic bands) after surgery. Over the following 10 weeks, you will slowly advance your diet from puréed to soft to regular foods.
• Avoid strenuous activity for six to 12 weeks after surgery.
• Return to work three to six weeks after surgery.

When to Seek Medical Attention

Your surgeon will provide specific instructions for when to call or seek emergency care.

General symptoms that warrant medical attention right away include:

• Uncontrollable pain
• Fever or chills
• Significant bleeding
• Calf or leg pain
• Chest pain or trouble breathing

Long-Term Care

After surgery, you will see your surgeon for multiple follow-up appointments. There, they will evaluate how well your wound/surgical sites are healing and monitor you for complications and side effects related to the particular intervention performed.

Then, around four months or so after your surgery, you will undergo a repeat home or in-center sleep apnea study. The purpose of this is to evaluate whether surgery improved or cured your OSA. 

Assuming a successful surgical outcome, you will want to engage in healthy lifestyle habits to prevent your OSA from recurring or worsening. These practices include maintaining/achieving a healthy weight through diet and exercise (and sometimes medication or surgery) and seeing your sleep medicine doctor as advised.

Smoking cessation and limiting alcohol intake are also prudent strategies to lowering the chances of your OSA returning or worsening.

A Word From Verywell

OSA is a serious and complex condition that warrants a commitment to treatment. If you are curious about surgical options that might be helpful to improve sleep apnea, speak with your sleep specialist and consider referral to a surgeon for additional evaluation of the potential risks and benefits in your case.