OVERVIEW OF ADULT SLEEP APNEA SURGERY
Kasey K. Li, MD, DDS, FACS
Obstructive sleep apnea syndrome is the result of upper
airway obstruction from repetitive airway narrowing and closure during sleep.
It is associated with increased cardiovascular morbidity and mortality.1,2 The psychomotor sequelae of obstructive
sleep apnea, such as excessive daytime
sleepiness, daytime fatigue and poor sleep quality due to sleep fragmentation,
are also well established. 3,4 Currently, nasal continuous positive airway pressure (CPAP) is the first
line of treatment. Indeed, the effectiveness of nasal CPAP in improving the
sequelae of obstructive sleep apnea is irrefutable. 5,6 Nevertheless, patient compliance represents
a clear problem. 7 Furthermore, even in compliant patients who are using CPAP on a "regular
basis," the actual usage is only approximately 50% of the ideal.8 Due to the limitations of CPAP, surgical
treatment of OSA should be considered as a viable treatment option.
This review will present the current
state of art in sleep apnea surgery, beginning with evaluation of the patient
as surgical candidate to formulation of a surgical plan through procedural
selection based on published surgical outcomes.
procedures are currently available for the treatment of obstructive sleep
apnea. However, the following issues present a formidable challenge to the
sleep apnea surgeon: 1) the complex interplay of the soft and hard tissues that
contribute to upper airway obstruction; 2) the crucial role of this anatomic
region to speech and swallowing; and 3) the subsequent edematous response after
surgical intervention. Moreover, it is well accepted that successful surgical
outcomes depend on proper patient selection as well as the choice of surgical
procedure(s). Therefore, a logical and systematic approach to clinical
evaluation, treatment planning, surgical execution and perioperative management
is necessary to maximize safety and improve outcomes.
must include the overall body habitus (height, weight and neck circumference),
since it has been shown that surgical outcomes can be influenced by these
factors. 9 Obviously, a
detailed examination should focus on the head and neck region in order to
identify the potential sites of upper airway obstruction, including the nose,
soft palate, lateral pharyngeal walls and tongue base. The presence of nasal
septal deviation, turbinate hypertrophy, nasal valve collapse, elongation of
the soft palate/uvula, tonsillar hypertrophy, enlargement of the tongue,
narrowed and/or deficient maxilla and mandible are many of the common findings
in patients with obstructive sleep apnea. By using fiberoptic nasopharyngoscopy
and lateral cephalometry along with direct visual examination, the upper airway
can be completely assessed for anatomic abnormalities that may be contributing
to obstructive sleep apnea.
Airway examination by a fiberoptic
scope is highly recommended in patients with obstructive sleep apnea. This
evaluation enables the examiner to directly visualize the entire upper airway
from the nose to the larynx. The
dimension of the nasal, velopharyngeal and hypopharyngeal airway can be fully
assessed. Furthermore, the prominence of the tongue base and the lateral
pharyngeal wall, as well as their collapsibility, can be evaluated with the
Muller's maneuver. 10
Lateral Cephalometric Radiograph
Many airway imaging
methods are currently available. Computed tomography (CT) or magnetic resonance (MR) can precisely assess
the dimension of the upper airway. 11,12 However, due to cost constraints, none can be widely used in
clinical practice except the lateral cephalometric radiograph. Although lateral cephalometric radiograph is
only a static two-dimensional method of evaluating a dynamic three-dimensional
area, it is a valuable study in identifying abnormal facial skeletal anatomy
that may contribute to airway obstruction as well as the relation of the hard
and soft tissues of the airway. Furthermore, lateral cephalometric radiograph provides useful
information on the posterior airway space behind the soft palate and the tongue
base. The posterior airway space
measurement on lateral cephalometric radiograph has been shown to correlate
with the volume of hypopharyngeal airway on three-dimensional CT scans. 13
The relationship between nasal obstruction and
sleep-disordered breathing has been demonstrated by numerous investigations.
Both daytime nasal obstruction and nocturnal nasal congestion have been shown
as risk factors for sleep-disordered breathing.14,15 Therefore, the treatment of nasal
obstruction plays an important role in sleep apnea surgery. However, it must be emphasized that although
obstructive sleep apnea can be improved in some patients, only slight
improvement has been shown.16,17 Three anatomic areas of the nose that may
contribute to obstruction are the alar cartilage/nasal valve region, the septum
and the turbinates. The most common nasal surgical procedure consists of
septoplasty and turbinate reduction. The major effects of nasal surgery are
subjective improvement of nasal patency and reduction of the nasal CPAP
has been the most common sleep apnea surgical procedure performed during the
past 25 years.18 Traditional
uvulopalatopharyngoplasty procedure consists of the removal of redundant soft
palate and pharyngeal tissues as well as uvula, so as to widen the
oropharyngeal inlet. The tonsillar
tissues are also removed if present. Although uvulopalatopharyngoplasty can significantly improve
oropharyngeal obstruction, hypopharyngeal obstruction is minimally affected by
the procedure, thereby reflecting a success rate of only approximately 40%. 19 Furthermore, potential complications
including velopharyngeal insufficiency, stenosis and dysphagia are major
concerns. Consequently, several
modifications of the traditional procedure have been developed to improve
outcomes and reduce complications.
The uvulopalatal flap
procedure is a modification of uvulopalatopharyngoplasty, which results in the
widening of the oropharyngeal airway by suspension of the uvula superiorly
toward the hard-soft palate junction after a limited resection of the uvula,
lateral pharyngeal wall and the mucosa. 20 As such, this surgical technique results in the widening of the
oropharyngeal airway. A prospective study of 80 patients with variables
including age, sex, body mass index, soft palatal length, respiratory
disturbance index (RDI), lowest oxygen desaturation (LSAT) and subjective
snoring scale demonstrated that there was no statistical significant difference
between the uvulopalatal flap group and the uvulopalatopharyngoplasty
group. Using a visual analog scale to
assess pain, there was significantly less pain in the uvulopalatal flap group
vs. the uvulopalatopharyngoplasty group.
pharyngoplasty procedure is another modification of the
uvulopalatopharyngoplasty. This procedure usually involves the removal of
tonsillar tissues, but the uvula and the soft palate is preserved. The pharyngeal inlet is widened and the
airway collapsibility is reduced purely via suturing of the tonsillar wounds. This procedure represents the most
conservative pharyngeal surgery and has minimal side effects as compared to
other procedures. This is the preferred
procedure by the author.
Uvulopalatoplasty (LAUP) was introduced by Kamimi as an office-based surgical
procedure for the treatment of snoring. 21 The procedure involves removal of the uvula and a portion of the
soft palate by carbon dioxide laser incisions and vaporization. Most of the uvula is amputated, and the soft palate (1-2 cm lateral to the uvula) is
incised and vaporized. Additionally,
mucosal or tonsillar pillar tissue is vaporized as needed.
Although many studies
have evaluated the efficacy of LAUP in the treatment of OSA, most of the studies
are flawed by methodological discrepancies or statistical inadequacies such as
ill-defined criteria for response and lack of adequate follow-up. In addition, LAUP is associated with
increased risk of dysphagia as well as the risk of discontinuation of treatment
due to pain. 22,23 Moreover,
recent AASM evidence-based guidelines do not support the use of LAUP in the
treatment of obstructive sleep apnea. 24
The mandible and the
tongue are major determinants of the airway dimension. Anterior positioning of these structures has
been shown to improve obstructive sleep apnea. The genioglossus advancement
procedure is limited to moving forward the geniotubercle with the genioglossus
insertion without moving the mandible. This advancement places tension on the
tongue musculature, thereby limiting the posterior displacement during
sleep. The genioglossus advancement
procedure consists of a rectangular osteotomy on the symphysis of the mandible
intraorally. The rectangle is advanced forward by the thickness of the mandible
and partially rotated to prevent retraction back into the floor of the
mouth. Incorporation of the
geniotubercle during the procedure has been shown to be quite successful with
this technique. 25 In
general, genioglossus advancement is performed with other sleep apnea surgical
procedures such as UPPP and hyoid advancement in order to maximize
improvement. The results from these
procedures have been variable, ranging from 23% to 77%. 26-29 These variable results underline the
difficulty in accurately predicting the success rate. Clearly, anatomic factors, body habitus and obstructive sleep
apnea severity are all factors that influence surgical success. In general, the potential risks associated
with genioglossus advancement are quite limited, including infection, hematoma,
injury to the genioglossus muscle and paresthesia of the lower teeth.
The hyoid bone holds
an intimate relationship with the tongue base and pharyngeal musculature, thus
portraying an integral aspect of the upper airway anatomy. The hyoid bone may be surgically
repositioned anteriorly by attaching it to the thyroid cartilage in order to
expand the airway. 30 The
procedure is usually performed in conjunction with genioglossus advancement so
as to contribute to the improvement of obstructive sleep apnea. 28,29, 31 However, some
surgeons have elected to combine it with UPPP alone. 32 An inherent problem with hyoid advancement
is the requirement of an external incision on the neck, one aspect that may not
be readily accepted by all patients. As
with other sleep apnea surgical procedures, the results of hyoid advancement
are variable, ranging from 23% to 65%. 28-31 In general, the
associated surgical risks are low, and may include infection, seroma formation
Abnormality of the maxillofacial skeleton is a
well-recognized risk factor of obstructive sleep apnea. 18,19 Maxillomandibular advancement was initially
advocated based on the finding that maxillofacial skeletal abnormality (i.e.,
maxillary and/or mandibular deficiency) is frequently found in patients with
obstructive sleep apnea, and that maxillomandibular deficiency results in
diminished airway dimension, which leads to nocturnal obstruction. Maxillomandibular advancement achieves
enlargement of the entire upper airway including the nasal, pharyngeal and
hypopharyngeal airway expansions of the skeletal framework that encircle the
airway. Comparison of pre- and
post-operative airway appearance based on fiberoptic nasopharyngoscopy and
lateral cephalometric radiograph have demonstrated that in addition to airway
expansion by the forward movement of the maxillomandibular complex, the tension
and collapsibility of the suprahyoid and velopharyngeal musculature may also be
reduced, thus leading to the reduction of lateral pharyngeal wall collapse. 33
advancement procedure consists of mobilizing the maxilla and mandible to
achieve anterior displacement of the maxillomandibular complex after intraoral
osteotomy of the maxilla and mandible. The maxilla and mandible are stabilized with titanium plates in the
advanced position. In order to maximize
the airway expansion, an advancement of 10-12 mm is usually recommended. However, it is important to achieve maximal
advancement while maintaining a stable dental occlusion as well as balanced
aesthetic appearance. Interestingly,
although many patients may be left with "prominent jaws," very few of them are
dissatisfied with their appearance. 34
advancement is the most effective sleep apnea surgical procedure currently
available. The success rate is usually between 75% and 100% 27,28,35,36 with a long-term success rate approaching 90%.37,38 In addition, patient perception of the
surgical outcome has been very favorable. 35 Although maxillomandibular advancement is
considered a fairly invasive procedure, the associated surgical risks are low,
including bleeding, infection, malocclusion and permanent numbness.
A constricted maxilla with a high and narrowed hard palate
contributes to increased nasal resistance39-41 and is a common
finding in patients with obstructive sleep apnea. 42,43 Investigators have demonstrated that expansion
of the maxilla can improve obstructive sleep apnea in children and adolescents
as well as adults. 44,45 Furthermore, since patients with maxillary constriction often have a
corresponding mandibular constriction, expansion of the maxillary and mandibular
complex has also been shown to be beneficial in reducing the severity of
obstructive sleep apnea. 46 The procedure consists of limited osteotomies to allow widening of the
maxilla and mandible with distractors. The advantage of maxillomandibular expansion is that it is considerably
less invasive than maxillomandibular advancement. However, treatment time is lengthened and patients need to keep
the distractors in place for several months after the operation to ensure that
the expansion is stable. Therefore,
patient acceptance for this treatment option may be affected. In addition, orthodontic therapy is also
mandatory and may possibly influence patient acceptance of this treatment
Radiofrequency Tongue Base Reduction
Low-wave radiofrequency energy achieves therapeutic
ablation of tissue in a minimally invasive fashion. Radiofrequency can be safely applied to the upper airway tissue
to improve OSA by volumetric tissue reduction and tissue stiffening.
energy delivery to the upper airway tissue occurs through a needle
electrode. The energy current causes
ionic agitation of the tissue around the electrode, resulting in frictional
heating of the tissue. Therefore, the
electrode itself does not get hot; heat actually emanates from the tissue. Tissue injury occurs when the temperature
reaches beyond 47°C, which is when cell proteins undergo denaturation. The
size of the lesion (area of tissue injury) created on the tongue is dependent
on the current intensity and the duration of energy delivery. 47 Typically, the lesion is in the shape of an
ellipse, with the long axis of the lesion approximating two times the length of
the needle electrode and the transverse axis approximating two-thirds of the
radiofrequency energy disbursement is proportional to 1/radius4,
heat dissipation is limited and excessive tissue injury is minimized. Furthermore, when the temperature reaches
90-100°C, char formation on the electrode leads to an increase in impedance and
results in disruption of current flow, thus serving as a second layer of
protection. These factors allow radiofrequency ablation to create a predictable
tissue injury pattern, thereby minimizing potential complications.
prospective study of radiofrequency tongue reduction was conducted in 18
patients. 48 After a mean
total energy of 8490 joules was delivered per patient over a mean of 5.5
treatments, the mean RDI improved from 39.6 to 17.8 with an improved LSAT from
81.9% to 88.3%. The tongue volume was
reduced by a mean of 17% (based on MRI findings). There were no changes in speech or swallowing. Complications
included a superficial tongue ulceration that resolved spontaneously,
persistent pain on swallowing that resolved after several weeks, and a tongue
abscess that required drainage. Sixteen of the 18 patients were followed on a long-term basis
(mean of 28 ± 4 months). 49 Findings demonstrated a mean weight increase
of 3.1 ± 7.9 kg. In addition, there was a worsening of RDI
from 17.8 to 28.7. There was also a
worsening trend in the LSAT from 88.1% to 85.8%. However, there was no significant deterioration of the quality of
life measurements by SF-36 or daytime sleepiness by Epworth Sleepiness Scale
reports have shown radiofrequency tongue reduction to be efficacious in
improving obstructive sleep apnea. 50-52 However, based on all reports, improvement with radiofrequency
tongue reduction is insufficient as a single treatment modality. Therefore, it should most likely be
considered as an adjunctive treatment in combination with other surgical
The use of
tracheostomy to bypass upper airway obstruction in "Pickwickian" patients was
the first reported treatment for obstructive sleep apnea.53 Despite being the most effective treatment
for obstructive sleep apnea, patient acceptance is low due to the associated
morbidity and social implications. The current use of tracheostomy primarily
serves as a temporary measure for airway protection in patients with severe
sleep apnea with either morbid obesity or significant craniofacial anomalies that
pose a high risk for airway compromise in the perioperative period. 54,55 However, permanent tracheostomy as a
long-term treatment of obstructive sleep apnea remains an option in morbidly
obese patients with obesity hypoventilation syndrome or in patients with
significant craniofacial anomaly who have failed all other forms of
non-surgical and surgical treatments. 56-58
prior to any sleep apnea surgery, the diagnosis of obstructive sleep apnea
based on sleep study results is essential. Although some may debate whether a formal polysomnography should be
mandatory, the use of an ambulatory sleep study is an acceptable practice under
current standards. The selection of
surgical procedure(s) is based on numerous factors (Table 1). The patient's desire and preference as well
as the health status can clearly influence outcomes and must be taken into
consideration. Additionally, the goal of surgery may be different for patients. Although the majority elect surgical
treatment due to intolerance of non-surgical treatments, some patients may
consider surgery in order to improve their ability to tolerate non-surgical
treatments, such as the reduction of therapeutic CPAP pressure or improvement
of nasal symptoms due to CPAP use. Therefore,
the surgical endpoint should be discussed prior to surgery, along with criteria
for surgical success (Table 2). Informed consent must be conducted, and patients should be educated
regarding the rationale of surgery as well as associated risks and benefits.
formulating a surgical plan, the most difficult task for the surgeon is to
decide which procedure(s) should be utilized. Indeed, information gathered from the pre-operative assessment including
clinical examination, fiberoptic nasopharyngoscopy and lateral cephalometric
radiograph can provide useful information regarding the upper airway anatomy
and the site(s) of obstruction. Nevertheless, the only surgical procedure that has been able to achieve
a consistently significant response rate is maxillomandibular advancement. Other surgical procedures that are less
invasive are often much less predictable and clearly less successful,
especially in patients with severe obstructive sleep apnea. Thus, as the severity of the obstructive
sleep apnea increases, so will the invasiveness of the procedures needed to
Clearly, the most
logical surgical approach would be to minimize surgical intervention and avoid
unnecessary surgery while achieving a successful result. Therefore, the majority of surgeons have
favored a staged surgical protocol. Since uvulopalatopharyngoplasty or uvulopalatal flap and
genioglossus/hyoid advancement are all rather limited procedures without
significant surgical morbidity, these procedures are usually first attempted to
improve obstructive sleep apnea. After
a healing period of four to six months, a post-operative polysomnogram is
obtained to evaluate outcome. In
patients with persistent obstructive sleep apnea, maxillomandibular advancement
can then be performed. Uvulopalatopharyngoplast/uvulopalatal flap in combination with
genioglussus/hyoid advancement is usually considered as phase I operation, in
which these procedures are often performed as a single operation. Maxillomandibular advancement is considered
as phase II operation.
However, the staged
approach may actually increase unnecessary surgical manipulation for some
patients. Patients with factors that
can negatively influence the outcome may have a
low chance of success with phase I operation (Table 1). Therefore, patients with severe obstructive
sleep apnea, morbid obesity or significant hypopharyngeal obstruction such as
severe mandibular deficiency, or patients who wish to have the best chance for a
cure with a single operation can certainly be considered as candidates for
maxillomandibular advancement as a primary surgical treatment option. Clearly, it is important to review all
possible treatment options and explain the rationale for sleep apnea surgery. In the author's opinion, combining all of
the procedures in a single operation should be cautioned due to the potential
for unnecessary surgery, as well as increased surgical morbidity and
post-operative airway compromise.
Successful surgical outcome depends on proper patient
selection as well as the choice of surgical procedure(s). The adaptation of a logical and systematic
approach to clinical evaluation, treatment planning and surgical execution is
necessary in order to maximize safety and improve surgical results. New surgical techniques and evolving
technology may potentially offer less invasive treatment modalities with
broader patient acceptance and improvement in results.
1. Shahar E, Whitney CW,
Redline S, Lee ET, Newman AB, Javier Nieto F, O'Connor GT, Boland LL, Schwartz
JE, Samet JM. Sleep-disordered
breathing and cardiovascular disease: cross-sectional results of the Sleep
Heart Health Study. Am J Respir Crit
Care Med 2001;163:19-25.
2. Peker Y, Hedner J,
Kraicze H, Loth S. Respiratory
disturbance index: an independent predictor of mortality in coronary artery
disease. Am J Respir Crit Care Med
3. Gottlieb DJ, Whitney
CW, Bonekat WH, Iber C, James GD, Lebowitz M, Nieto FJ, Rosenberg CE. Relation of sleepiness to respiratory
disturbance index: the Sleep Heart Health Study. Am J Respir Crit Care Med 1999;159:502-507.
4. Young T, Paltz M,
Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged
adults. N Engl J Med
5. Jenkinson C, Davies
RJ, Mullins R, Stradling JR. Comparison
of therapeutic and subtherapeutic nasal continuous positive airway pressure for
obstructive sleep apnoea: a randomized prospective parallel trial. Lancet 1999;353:2100-2105.
6. Hack M, Davies RJ,
Mullins R, Choi SJ, Ramdassingh-Dow S, Jenkinson C, et al. Randomised prospective parallel trial of
therapeutic versus subtherapeutic nasal continuous positive airway pressure on
simulated steering performance in patients with obstructive sleep apnoea. Thorax 2000;55:224-231.
7. Kribb NB, Pack AI,
Kline LR, Schwartz AR, Schubert NM, et al. Objective measurement of pattern of nasal CPAP use by patients with
obstructive sleep apnea. Am Rev Respir
8. Grote L, Hedner J,
Grunstein R, Kraiczi H. Therapy with
nCPAP: incomplete elimination of sleep-related breathing disorder. Eur Respir J 2000;16:921-927.
9. Li KK, Powell NB,
Riley RW, et al. Morbidly Obese
Patients with Severe Obstructive Sleep Apnea Syndrome: Is Airway Reconstructive
Surgery a Viable Option? Laryngoscope
LS, Golish JA, Wood BG, Mehta AC, Wood DE, Dinner DS. Dynamic pharyngoscopy in predicting outcome of
uvulopalatopharyngopasty for moderate and severe obstructive sleep apnea. Chest 1995;107:946-951.
NH, Li KK, Chuang ML, Li SY, Wong CR, Wu YK. Airway Assessment by Volumetric CT in Snorers and Subjects with
Obstructive Sleep Apnea. Laryngoscope;
RJ, Gupta KB, Gefter WB, et al. Upper
airway and soft tissue anatomy in Normal subjects and patients with
sleep-disordered breathing. Am J Respir
Crit Care Med 152:1673-89, 1995.
RW, Powell NB. Maxillofacial surgery
and obstructive sleep apnea syndrome. Otolaryngol Clin N Am 23:809-826, 1990.
F, Coste AD, Ortho MP, Zerah-Lancner F, Delclaux C, Goldenberg F, Harf A. Nasal obstruction as a risk factor sleep
apnea syndrome. Eur Respir J
T, Finn L, Palta M. Chronic nasal
congestion at night is a risk factor for snoring in a population-based cohort
study. Arch Int Med 2001;161:1514-1519.
M, Tanyeri H, Lim JW, Landsberg R, Vaidyanathan K, Caldarelli D. Effect of improved nasal breathing on
obstructive sleep apnea. Otolaryngol
Head Neck Surg 2000;122:71-74.
T, Maurer JT, Pirsig W. Effect of nasal
surgery on sleep-disordered breathing disorders. Laryngoscope 2002;112:64-68.
S, Conway W, Zorick F, Roth T. Surgical
correction of anatomic abnormalities of obstructive sleep apnea syndrome:
Head Neck Surg 1981;89:923-934.
AE, Schechtman KB, Piccirillo JF. The
efficacy of surgical modifications of the upper airway in adults with
obstructive sleep apnea syndrome. Sleep
NB, Riley RW, Guilleminault C, Troell RJ. A reversible uvulopalatal flap for snoring and obstructive sleep. Sleep 19:593-599, 1996.
YV. Laser CO2 for snoring-preliminary
results. Acta Otorhinolaryngol Belg
DST, Weng JCM, Cheng LHS. Carbon
dioxide laser surgery for snoring: Results in 192 patients. Otolaryngol Head Neck Surg 1998;
23. Astor FC, Hanft K, Benson C, et al. Analysis of short-term outcome after
office-based laser-assisted uvulopalatoplasty. Otolaryngol Head Neck Surg 1998; 118:478-480.
M, Kushida CA, Hartse K, et al Practice
parameters for the use of laser-assisted uvulopalatoplasty: an update for
2000. Sleep 24:603-19, 2001.
KK, Riley RW, Powell NB, Troell RJ. Obstructive sleep apnea surgery: genioglossus advancement
revisited. J Oral Maxillofac Surg
KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Overview of Phase I surgery for Obstructive sleep apnea
syndrome. ENT J 78:836-845, 1999.
NR, Givens CD Jr, Wilson J, Robins RB. Staged surgical treatment of obstructive sleep apnea syndrome: a review
of 35 patients. J Oral Maxillofac Surg
G, Pepin J, Veale D, et al. Obstructive
sleep apnea syndrome: Fifty-one consecutive patients treated by maxillofacial
surgery. Am J Respir Crit Care Med
PP, Brett RH. Multiple level pharyngeal
surgery for obstructive sleep apnoea. Singapore Med J 42:160-164, 2001.
RW, Powell NB, Guilleminault C. Obstructive sleep apnea and the hyoid: A revised surgical procedure. Otolaryngol Head Neck Surg 1994;111:717-721.
C. Genioglossus advancement and hyoid
myotomy under local anesthesia. Otolaryngol Head Neck Surg 129:85-91, 2003.
T, Baisch A, Hormann K. Multi-level
surgery for obstructive sleep apnea. Preliminary objective results. Laryngorhinootologie 2004;83:516-522.
KK, Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea and maxillomandibular advancement: An assessment
of airway changes using radiographic and nasopharyngoscopic examination. J Oral Maxillofac Surg 2002;60:526-530.
KK, Riley RW, Powell NB, Guilleminault C. Patient's Perception of the Facial Appearance after Maxillomandibular
Advancement for Obstructive Sleep Apnea Syndrome. J Oral Maxillofac Surg 2001;59:377-380.
KK, Riley RW, Powell NB, et al. Obstructive Sleep Apnea Surgery: Patients' Perspective and
Polysomnographic Results. Otolaryngology - Head and Neck Surgery 123:572-575, 2000.
KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Overview of Phase II surgery for Obstructive sleep apnea
syndrome. ENT J 78:851-857, 1999.
KK, Powell NB, Riley RW, et al. Long-term Results of Maxillomandibular Advancement Surgery. Sleep and Breathing 4:137-139, 2000.
R, Hochban W, Brandenburg U, Heitmann J, Peter JH. Long term results after surgical treatment of obstructive sleep
apnea by maxillomandibular advancement. Eur Respir J 10:123-128, 1997.
PA, Richards GN, Palmisano RG, Unger G, Berthon-Jones M, Sullivan CE. Influence of maxillary constriction on nasal
resistance and sleep apnea severity in patients with Marfan's syndrome. Chest 1996;110:1184-1188.
DJ. Rapid maxillary expansion in the
treatment of nocturnal enuresis. Angle
J, Modin H, Bjerkhoel A. Orthodontic
maxillary expansion and its effect on nocturnal enuresis. Angle Orthod 1998;68:225-232.
BH, Gotsopaulos H, Sims MR, Cistulli PA. Maxillary morphology in obstructive sleep apnea syndrome. Eur J Orthod 2001;23:703-714.
C, Efron B, Guilleminault C. A
predictive morphometric model for the obstructive sleep apnea syndrome. Ann Int Med 1997;127:581-587.
PA, Palmisano RG, Poole MD. Treatment
of obstructive sleep apnea syndrome by rapid maxillary expansion. Sleep 1998;21:831-835.
P, Saponara M, Guilleminault C. Rapid
maxillary expansion in children with obstructive sleep apnea syndrome. Sleep 2004;27: 761-766.
C, Li KK. Maxillomandibular Expansion
by Distraction Osteogenesis for the Treatment of Sleep-Disordered Breathing:
Preliminary Results. Laryngoscope;
NB, Riley RW, Troell RJ, et al. Radiofrequency volumetric reduction of the tongue. Chest 111:1348-55, 1997.
NB, Riley RW, Guilleminault C. Radiofrequency tongue base reduction in sleep-disordered breathing: a
pilot study. Otolaryngol Head Neck Surg
KK, Powell NB, Riley RW, Guilleminault C. Temperature-Controlled Radiofrequency Tongue Base Reduction for
Sleep-Disordered Breathing: Long-term Follow-up. Otolaryngol Head Neck Surg
BA, Maurer JT, Verse T, Hormann K. Tongue base reduction with temperature-controlled radiofrequency
volumetric tissue reduction for treatment of obstructive sleep apnea
syndrome. Acta Otolaryngol
BT, Nelson L, Mickelson S, Huntley T, Sher A. A multi-institutional study of radiofrequency volumetric tissue
reduction for OSAS. Otolaryngol Head
Neck Surg 2001;125:303-311.
Y, Khan M, Mann WJ. Multilevel
temperature-controlled radiofrequency therapy of soft palate, base of tongue,
and tonsils in adults with obstructive sleep apnea. Laryngoscope 2003;113:1786-1791.
W, Doll E, Franck MD. Erfolgreiche
Behandlung eines Pickwick Syndroms durch eine Dauertrachekanuele, Dtsch Med
Wochenschr 94:1286-1290, 1969.
KK, Riley RW, Powell NB, Troell RJ, Guilleminault C. Overview of Phase II Surgery for Obstructive Sleep Apnea
Syndrome. ENT J 1999; 78:851-857.
KK, Powell N, Riley R. Postoperative
management of the obstructive sleep apnea patients. Oral Maxfac Surg Clin N Am 2002;14:401-404.
A, De Vito A, Frassineti S, Vicini C. Role of skin-lined tracheotomy in obstructive sleep apnoea syndrome:
personal experience. Acta Otorhinolaryngol
JJ, Laurikainen EA, Halme P, Antila J. Long-term results of tracheostomy for severe obstructive sleep apnea
syndrome. ORL Otoihinolaryngol Relat
SH, Eisele DW, Smith PL, Schneider H, Schwartz AR. Evaluation of patients with sleep apnea after tracheotomy. Arch Otolaryngol Head Neck Surg
Table 1: Factors influencing sleep apnea surgery
||Younger patients (< 60 y.o.)
patients (> 60 y.o.)
||Mild to moderate (RDI < 30)
(RDI > 30)
|Site of obstruction
Table 2: Defining surgical
in quality of life with reduction of sleep apnea symptoms
RDI to less than 20 and reducing RDI by greater than 50%
of oxygen nadir to 90% with few desaturations to below 90%