uvulopalatopharyngoplasty, or UPPP procedure

The most common surgery for sleep apnea is the uvulopalatopharyngoplasty, or UPPP procedure, which is intended to enlarge the airway by removing or shortening the uvula and removing the tonsils and adenoids, if present, as well as part of the soft palate or roof of the mouth. (The uvula is the tissue that hangs from the middle of the back of the roof of the mouth; the word comes from the Latin “uva” meaning “grapes.”) According to the “Practice Parameters for the Treatment of Obstructive Sleep Apnea: Surgical Modifications of the Upper Airway,” issued in 1996 by the American Academy of Sleep Medicine (formerly the American Sleep Disorders Association), the overall efficacy is 40.7%. A more recent surgery using a laser (laser-assisted uvulopalatoplasty or LAUP, a modification of the UPPP where the surgeon cuts the uvula with a laser) is performed for snoring. There is not yet enough information to say whether LAUP is effective for OSA.

 

CONSIDERING SURGERY FOR OSA?

With obstructive sleep apnea (OSA), blockages somewhere in the airway occur repeatedly and cause breathing to stop for at least ten seconds and maybe for a minute or longer. The intention of surgery is to open the airway sufficiently to eliminate or to reduce obstructions to a clinically insignificant level. In order to do so, surgical therapy in adults often must reconstruct the soft tissues (such as the uvula and the palate) or the bony tissues (the jaw) of the throat.

If you have been diagnosed with OSA and are considering surgery, talk to a sleep specialist and/or experienced surgeon about the different procedures, the chances they will be effective for you with your anatomy and why, and the risks involved with surgery. Untreated sleep apnea can be harmful to your health, and surgery cannot always address all the points of obstruction. Eliminating the snoring does not necessarily eliminate the apneas. Sometimes surgery does not cure sleep apnea but reduces the number of apneas so that more treatment options are available to you and/or more comfortable. Yet in some circumstances, surgery may actually worsen the apnea.
Insurance typically covers surgery for sleep apnea but not all surgical procedures. However, insurance companies that initially refuse to pay for a surgery may be convinced otherwise upon an appeal that demonstrates the efficacy and appropriateness of the surgery in your case. Throat pain from the major surgeries varies but is generally significant, often for one to two weeks. Most surgical procedures for sleep apnea are conducted in a hospital under general anesthetic. (People with sleep apnea must be cautious about general anesthesia–no matter for what medical condition the surgery is–because of the effects anesthesia has on the airway. For more on this, see our statement Sleep Apnea and Same-Day Surgery.)

The most common surgery for sleep apnea is the uvulopalatopharyngoplasty, or UPPP procedure, which is intended to enlarge the airway by removing or shortening the uvula and removing the tonsils and adenoids, if present, as well as part of the soft palate or roof of the mouth. (The uvula is the tissue that hangs from the middle of the back of the roof of the mouth; the word comes from the Latin “uva” meaning “grapes.”) According to the “Practice Parameters for the Treatment of Obstructive Sleep Apnea: Surgical Modifications of the Upper Airway,” issued in 1996 by the American Academy of Sleep Medicine (formerly the American Sleep Disorders Association), the overall efficacy is 40.7%. A more recent surgery using a laser (laser-assisted uvulopalatoplasty or LAUP, a modification of the UPPP where the surgeon cuts the uvula with a laser) is performed for snoring. There is not yet enough information to say whether LAUP is effective for OSA.

A tracheotomy–the surgical creation of a hole in the trachea or windpipe below the site of obstructions–is the most effective surgery for OSA. Unacceptable to most people, it is generally reserved for serious apnea that has failed other treatment. The hole is plugged (and usually covered) during the day for normal breathing and unplugged during sleep so obstructions are bypassed. The site must be cleaned carefully daily to prevent infections.

Other surgical procedures include laser midline glossectomy and lingualplasty where part of the tongue is removed. Two others which try to enlarge the airway by moving the jaw forward are maxillomandibular osteotomy or advancement (MMO or MMA) and the two-part inferior sagittal mandibular osteotomy and genioglossal advancement with hyoid myotomy and suspension (GAHM). These surgeries have very high success rates but are long and involved surgeries (lasting several hours) with a significant recovery period and potential complications that patients may reject. As a rule, success rates for these complicated surgeries are higher when performed by an experienced surgeon. You may have to undergo more than one surgery to eliminate the apneas sufficiently.

Another but relatively new surgical procedure for sleep apnea, one typically done in the doctor’s office, is radio frequency tissue ablation (RFTA), with the trade name Somnoplasty. Approved by the Food and Drug Administration in November of 1998, it is to shrink the size of the tongue and/or palate. Multiple treatments are often necessary, and it may be performed in conjunction with other therapies as well. RFTA is still viewed as a new procedure, and relatively little published data on the procedure are currently available. A different surgical system designed to treat OSA was approved by the FDA in February 1998. Known as the tongue suspension procedure (with the trade name Repose), it is intended to keep the tongue from falling back over the airway during sleep with a small screw inserted into the lower jaw bone and stitches below the tongue. Usually performed in conjunction with other procedures, this surgery is potentially reversible. No studies on the long-term success are available, and little clinical data to demonstrate the efficacy of the procedure have yet been published in a peer-reviewed journal.

In general, when weighing surgery, consider whether data on the safety and efficacy of the procedure have met the key standard of being published in a peer-reviewed medical journal and whether the cases studied are similar to yours. Surgery helps many, but effectiveness varies from person to person. (With any surgery, follow-up sleep studies are often adviseable.) If unsure about proceeding, you can get a second opinion. Only a doctor who has examined you and your airway can advise you on having surgery.

There are additional treatment options for OSA that do not require surgery, including devices to keep the airway open. As mentioned, some surgeries are performed to make using them more comfortable. Which treatment is right for you depends upon the severity of your OSA and other aspects of your medical condition. Talk to your doctor about what is best for you, and remember your doctor may take a step-wise approach to treatment.

Physicians who perform surgery for sleep apnea are most commonly otolaryngologists (specializing in the ears, nose, and throat) and oral and maxillofacial surgeons. If you are seeking a referral to a surgeon or a second opinion, you may find one through your physician or through a sleep center, and keep in mind that your insurance policy may require you to get a referral for a specialist and/or to see a specific provider.

As a non-profit organization, the American Sleep Apnea Association does not endorse or recommend any healthcare provider, company, or product. 8-00

source: http://www.sleepapnea.org/resources/pubs/osa.html

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