Structural surgery

Craniofacial and upper-airway structure, including the presence of mandibular or maxillary dysmorphisms, can contribute significantly to the development of OSA.28 In one study of 142 men without OSA (mean age 47 years; mean BMI 29 kg/m2) and 62 men with OSA (mean age 47 years; mean BMI 32 kg/m2), relative narrowness in the horizontal dimension of the maxilla was found to be the most important cephalometric measure in predicting AHI severity.28

In children, enlarged tonsils and adenoids can cause abnormal growth patterns of the lower face and jaw, predisposing these youths to OSA. In the recent Childhood Adenotonsillectomy Trial (CHAT), 464 children aged 5 to 9 years with OSA were randomized to early adenotonsillectomy or to watchful waiting.29 At 7 months, the surgery group exhibited significantly greater improvements than did the watchful-waiting group in behavioral, quality-of-life, and polysomnographic findings and significantly greater reductions in symptoms and AHI. This improvement was attributed to lymphoid tissue regression, airway growth, and routine medical care. Adenotonsillectomy did not, however, significantly improve attention or executive function as measured by neuropsychologic testing. 

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Individuals with OSA and anatomic obstruction, such as tonsillar hypertrophy that obstructs a pharyngeal airway, should be considered candidates for surgery when PAP therapy or oral appliances are ineffective or are declined. Numerous surgical approaches exist: 

  • Nasal surgery, including turbinectomy (removal of nasal turbinates) or correction of nasal septal deviation; polypectomy; rhinoplasty

  • Tonsillectomy and/or adenoidectomy (Figure 2)

  • Uvulopalatopharyngoplasty (UPPP)—reduction or removal of the uvula, the soft palate, the tonsils, the adenoids, and/or the pharynx. (Laser-assisted uvulopalatoplasty [LAUP] is not routinely recommended in OSA as this procedure does not generally normalize AHI and has not resulted in significant improvements in secondary outcomes.30) 

  • Radiofrequency ablation to reduce targeted tissue 

  • Tracheostomy—the most consistently effective surgical intervention for OSA yet also the last resort: It alters the patient’s appearance and places the patient at risk for aspiration, pneumonia, and vocal cord paralysis. Benefits include statistically significant decreases in AHI, hypopneas, and mortality.31
  • Maxillomandibular advancement (MMA) is the most effective surgical treatment for OSA excluding tracheostomy.32 However, this procedure leads to facial changes that may be unacceptable to patients with bimaxillary protrusion, a common feature of Asian faces. Liao et al. found that a modified MMA procedure consisting of osteotomies and postsurgical orthodontics was effective in treating OSA without affecting facial appearance or dental occlusion in Asians.32

Figure 2. Removal of enlarged tonsils can improve OSA symptoms.