Treatment of Obstructive Sleep Apnea: Overview
Obstructive Sleep Apnea (OSA) is a common disorder involving collapse of the upper airway during sleep. This repetitive collapse may result in sleep fragmentation, hypoxemia, hypercapnia, and increased sympathetic activity. OSA has been associated with an increased risk of many adverse health outcomes, including motor vehicle crashes, cognitive impairment, atrial fibrillation, stroke, and mortality. Daytime sleepiness and poor quality of life are other manifestations of OSA. As specialists in upper airway anatomy, physiology, and surgery, Otolaryngologists are uniquely qualified to treat patients with OSA.
Surgical management, specifically adenotonsillectomy, is the recommended first line treatment for moderate to severe OSA in children.1-3 Children with mild OSA may be managed with watchful waiting, medical therapy with anti-inflammatory medications, or adenotonsillectomy. Children with persistent OSA following adenotonsillectomy may be managed with additional surgical therapy such as lingual tonsillectomy or continuous positive airway pressure (CPAP). Drug induced sleep endoscopy (DISE) is useful to determine the best management strategy in children with persistent OSA.
In most adult patients with moderate to severe OSA, CPAP is the initial treatment modality. CPAP therapy can also be utilized to treat patients with mild OSA that have a high symptom burden such as excessive daytime sleepiness. However, CPAP is plagued with poor patient tolerance with a substantial proportion of patients not adhering to therapy.4 Tonsillectomy has been shown to be effective as a primary treatment in patients with OSA and enlarged tonsils.5,6 Surgical management may also be indicated for adult patients with OSA when PAP therapy is inadequate, such as when the patient is intolerant of CPAP or CPAP therapy is unable to eliminate OSA.7 For example, UPPP and tonsillectomy has been shown to be effective in improving OSA in approximately 80% of patients with favorable anatomy. Hypoglossal nerve stimulation therapy for OSA also results in improvement in quality of life, daytime sleepiness and reduction of AHI for select patients.8-10 Examples of additional surgical interventions that have demonstrated efficacy in treating OSA include palatal expansion, midline glossectomy, and epiglottectomy. Surgery for OSA has been shown to improve important clinical outcomes including survival and quality of life.11-13 DISE may be useful in determining the most effective OSA surgical treatment plan.
Nasal surgery, such as septoplasty, turbinate surgery, and procedures aimed to address nasal valve collapse, is a beneficial adjunct in the treatment of adult OSA.14-16 Nasal surgery results in improvement in daytime sleepiness and sleep quality. While the impact of nasal surgery on the AHI is often only modest, these procedures may result in a significant decrease in respiratory distress index.17 Nasal surgery offers the additional benefit of improving CPAP compliance.18,19
The primary non-surgical, non-CPAP therapy for adult OSA is an oral appliance. For patients with mild to moderate OSA, oral appliances can be used as a first-line treatment.20 These devices are very efficacious in the treatment of OSA and have better compliance than CPAP. To ensure efficacy patients should have a PSG once the device has been appropriately titrated.
- Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J,Simakajornboon N, Kaditis AG, Splaingard D, Splaingard M, Brooks LJ, Marcus CL,Sin S, Arens R, Verhulst SL, Gozal D. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med. 2010 Sep 1;182(5):676-83. Epub 2010 May 6. PubMed PMID: 20448096.
- Brietzke S, Gallagher D, The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: A meta-analysis Otolaryngol Head Neck Surg, 134(6), 979-984, 2006.
- Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376.
- Weaver TE, Grunstein RR; Adherence to continuous positive airway pressure therapy: the challenge to effective treatment, Proc Am Thorac Soc. 5(2):173-8, 2008
- Smith, Matthew M., Ed Peterson, and Kathleen L. Yaremchuk. “The Role of Tonsillectomy in Adults with Tonsillar Hypertrophy and Obstructive Sleep Apnea.” Otolaryngology–Head and Neck Surgery (2017): 0194599817698671.
- Martinho FL, Zonato AI, Bittencourt LRA, et al. Obese obstructive sleep apnea patients with tonsil hypertropy submitted to tonsillectomy. Braz J Med Biol Res, August 2006, Volume 39(8) 1137-1142.
- Epstein,EJ,(Chair), Kristo,D, Strollo, Jr.PJ, Clinical Guidelines for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. J Clin Sleep Med 5(3):263-79, 2009.
- Strollo P, Soose R, Maurer J, et al. Upper-Airway Stimulation for Obstructive Sleep Apnea. N Engl J Med. 2014;370(2):139-149.
- Boon M, Huntley C, Steffen A, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: Results from the ADHERE Registry. Otolaryngol – Head Neck Surg (United States). 2018. doi:10.1177/019459981876489
- Thaler E, Schwab R, Maurer J, et al. Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy. Laryngoscope. 2020. doi:10.1002/lary.28286
- Weaver EM, Maynard C, Yueh B. Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery. Otolaryngol Head Neck Surg 130(6):659-65. 2004.
- Randerath WJ, Verbraecken J, Andreas S, et al. Non-CPAP therapies in obstructive sleep apnea. Eur Respir J 2011; 37: 1000-1028
- Friedman, Michael, Hani Ibrahim, and Ninos J. Joseph. “Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment.” The Laryngoscope 114.3 (2004): 454-459.
- Park CY, Hong JH, Lee JH, et al. Clinical effect of surgical correction for nasal pathology on the treatment of obstructive sleep apnea syndrome. PLoS One. 2014;9:e98765.
- Bican A, Kahraman A, Bora I, et al. What is the efficacy of nasal surgery in patients with obstructive sleep apnea syndrome: J Craniofac Surg. 2010;21:1801-1806.
- Ishii L, Roxbury C, Godoy A, Ishman S, Ishii M. Does nasal surgery improve OSA in patients with nasal obstruction and OSA? A meta-analysis. Otolaryngol Head Neck Surg. 2015;153:326-333.
- Wu J, Zhao G, Li Y, et al. Apnea-hypopnea index decreased significantly after nasal surgery for obstructive sleep apnea. Med (United States). 2017. doi:10.1097/MD.0000000000006008
- Camacho M, Riaz M, Capasso R, et al. The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: A systematic review and meta-analysis. Sleep. 2015. doi:10.5665/sleep.4414
- Poirrier J, George C, Rotenberg B. The effect of nasal surgery on nasal continuous positive airway pressure compliance. Laryngoscope. 2014;124:317-319.
- Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med. 2015 Jul 15;11(7):773-827.