Treatment of Obstructive Sleep Apnea: Overview
Obstructive Sleep Apnea (OSA) is a common disorder involving collapse of the upper airway during sleep. OSA has been associated with an increased risk of many adverse health outcomes, including motor vehicle crashes, cognitive impairment, cardiovascular events, atrial fibrillation, stroke, and mortality. This repetitive collapse may result in sleep fragmentation, hypoxemia, hypercapnia, and increased sympathetic activity. As specialists in upper airway anatomy, physiology, and surgery, Otolaryngologists are uniquely qualified to treat patients with OSA.
Surgical treatment of pediatric sleep disordered breathing with tonsillectomy and adenoidectomy is the recommended first line treatment.
In most adult patients with moderate to severe OSA, continuous positive airway pressure (CPAP) is the first line treatment. Surgical procedures may be considered as a secondary treatment for OSA when PAP therapy is inadequate, such as when the patient is intolerant of CPAP or CPAP therapy is unable to eliminate OSA (Consensus). UPPP and tonsillectomy has been shown to be effective in 80% patients with favorable anatomy. Tonsillectomy alone has been shown to be effective in patients with enlarged tonsils. Surgery for OSA has been shown to improve important clinical outcomes including survival and quality of life. (Weaver 2004).
Septoplasty and or turbinate surgery has shown to be beneficial in the treatment of excessive daytime sleepiness (ESS), results in a decrease in respiratory distress index (RDI) and apnea-hypopnea index (AHI), and improves quality of life in patients with obstructive sleep apnea.
Surgery may also be considered as an adjunct therapy when there is obstructive anatomy that compromises the use of other therapies or to increase use of PAP or oral appliances (Consensus; Epstein 2009) Surgery for tonsillar hypertrophy, turbinate hypertrophy and septal deviation have been shown to improve CPAP compliance (Randerath 2011).
- 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.
- 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.
- 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.
- 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
- 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.
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.
- 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.
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.
- Nakata S, Miyazaki S, Ohki M, et al. Reduced nasal resistance after simple tonsillectomy in patients with obstructive sleep apnea. Am J Rhinol 21: 192-195, 2007.
Randerath WJ, Verbraecken J, Andreas S, et al. Non-CPAP therapies in obstructive sleep apnea. Eur Respir J 2011; 37: 1000-1028
- 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.
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.
- Poirrier J, George C, Rotenberg B. The effect of nasal surgery on nasal continuous positive airway pressure compliance. Laryngoscope. 2014;124:317-319.
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.
Important Disclaimer Notice (Updated 7/31/14)
Position statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.