An inherent problem in obstructive sleep apnea (OSA) for any given individual is that the airway is structurally vulnerable to collapse. Multiple physiologic and anatomic factors contribute to maintain airway patency. The complex interaction between respiratory control, arousal thresholds, neuromuscular tone, and transmural pressure in the pharynx determine the patency of the airway through the respiratory cycle. Simply put, the upper airway including the pharynx and to a lesser degree the nasal cavity can be thought of as a collapsible tube. The flow of air through the upper airway is influenced by the difference in upstream, downstream, and intraluminal forces. Stabilization of airflow in an airway compromised by OSA often requires multimodality treatment.

Surgical treatments for sleep-disordered breathing (SDB) will vary depending on the structures involved and the morbidity of the intervention, severity of disease, obesity, and cost of care for many patients. The role of surgical intervention has classically been viewed as an attempt to influence the structures involved with airway collapse. An alternative and perhaps more accurate way of looking at the role of surgery is that of a reconstructive approach. The goal of airway reconstruction is to improve the patency of the tube and the flow of air. Ultimately, we want to reduce the severity of disease and sequelae. Surgical intervention is one modality that should be considered in patients presenting with SDB.

Surgical treatment often requires a combination of procedures. It is not a single unique surgery. In adults, a single anatomic structure is not usually the sole cause of obstruction, and multiple sites or levels of the airway often require treatment for optimal results. Although tracheotomy as a single procedure should be considered in certain clinical presentations of OSA, it is not practical in most cases. A vast array of surgical treatments are described and variable reported responses to them exist. This is in part due to the distinct character of each airway based on the craniofacial anatomy, neuromuscular tone, influence from other soft tissues, and physiologic elements. Understanding the pathophysiology of OSA along with the airway phenotype will aid in the selection and surgical application of procedures. Impacting only one of these factors surgically may be inadequate to achieve the desired end state. Ideally, the surgical approach is tailored to a patient rather than the application of a one method suits all approach.

The pathogenesis of SDB and luminal compromise is rarely confined to a single anatomic location. Obstruction and narrowing of both the upper pharyngeal (retropalatal) and lower pharyngeal (retroglossal) airways occurs in 70% to 80% of patients (1). Ethnic and gender variation may exist and not all sites contribute equally (2, 3, 4). Obstruction occurs in the pharynx for most events but obstruction of laryngeal tissues as a primary site is uncommon (4, 5). The cause of obstruction is complex, and abnormalities of palatal and pharyngeal muscles, mucosa, lymphoid tissues, vascular structures, and other influential elements such as airway mechanoreceptors have been reported. Abnormal nasal resistance is an important but indirect cause of apnea in adults. Ultimately, the common finding is an upper airway that is structurally vulnerable to collapse. Multiple surgeries and variations of them have been described with a desired effect of improving the flow of air during sleep.

Snoring has traditionally been regarded as a social nuisance rather than a source of morbidity. It is one of the most important presenting signs in patients suspected of having OSA. When patients present with a complaint of snoring, OSA needs to be ruled out rather than assuming a diagnosis of primary snoring. Data from the Wisconsin Sleep Cohort Study showed that 31% of middle-aged females and 53% of middle-aged males had habitual snoring and an even more had nonhabitual snoring (6). Treatment of snoring to this point has emphasized the importance on bed partner quality of sleep. However, new evidence is emerging that suggests there is an association
between snoring and increased mortality (7). Whether snoring is a discrete condition or there is a synergistic effect on SDB needs to be explored further.

Since surgery for sleep apnea is not a single intervention for many patients, algorithms describing planned interventions have been described. The most commonly quoted is the Stanford protocol that defines surgical procedures as being phase 1 or phase 2 procedures. Phase 1 procedures included segmental pharyngeal interventions such as uvulopalatopharyngoplasty (UPPP), genioglossal advancement, and hyoid suspension. Phase 2 procedures were maxillomandibular advancement or similar interventions (8). Others have described phased procedures using radiofrequency, lingual tonsillectomy, and glossectomy procedures as part of the phased protocol. To date, few studies have compared outcomes using different protocols. In addition to assessing how surgery may modify different structural elements of the airway, it is also important to define what the ultimate goal of surgical treatment for sleep apnea is going to be. Three general classifications for intervening may include complementing medical management (continuous positive airway pressure [CPAP] use, weight loss), salvage therapy in patients where medical management has failed, or when surgical cure is likely for select individuals. The treatment algorithm for patients may include a reassessment of prior failed therapies. It must also be recognized that OSA is a chronic disease and remittance is common. For a significant number of patients, CPAP tolerance following surgeries may be improved. Both retrospective and prospective studies suggest that nasal surgery may improve CPAP adherence and may lower CPAP pressures. Case series suggests that in some patients pharyngeal surgery may also improve CPAP use in selected patients. In the authors’ anecdotal experience, a subset of patients with marked lymphoid hyperplasia or other isolated soft tissue abnormalities may benefit from surgery that has the goal of improving CPAP use. Concerns exist, however, that aggressive UPPP may worsen CPAP use in some patients by creating or worsening “mouth leak.” Mouth leak occurs from over shortening of the palate, which then cannot seal against the tongue when positive pressures applied. The clinical significance of this is uncertain for most patients.

A successful outcome following surgery depends on at least three additional key elements. First, the preoperative clinical evaluation accurately defines the structures influencing the flow of air. A complementary or alternative way is describing the airway phenotype. Second, it is important to select the appropriate one or combination of procedures followed by skillful application of the procedure. The third element involves an understanding of what the potential effect of a procedure will be, the desired goal, and how the effect may change over time for a chronically, often progressive disease. An example of the latter class of patients is the nonobese pediatric patient with adenotonsillar hypertrophy and no other craniofacial or neurologic abnormalities.

In adults, positive airway pressure therapy is considered the gold standard although it does have its limitations. Certain patients are unable to tolerate positive airway pressure therapy. This is despite more sophisticated delivery methods available today. A variety of interfaces and other noninvasive pressure modalities may be beneficial for some patients. These include nasal masks including nasal pillows, masks which cover the nose and mouth, and full face masks. Varying positive pressure modalities also exist and include bilevel pressures (BiPAP), autotitrating units, devices with relaxation modes during exhalation, and newer devices with adaptive ventilation based on a continuous monitoring of flow through the device and interface.

Defining the criteria for successful outcome is also important. In the literature, this has traditionally focused on an improvement in respiratory parameters (apnea-hypopnea index [AHI], and lowest oxygen saturation [LSAT]). A threshold of treatment that defines a successful response does not exist based on current data. In addition to objective data, the subjective response should not be overlooked (9, 10). Subjective improvement in sleep with reduction in nasal airway obstruction (NAO), reduction in snoring, and improved quality of life should also be elements of the treatment discussion with the patient. The remainder of the chapter focuses on nasal and palate surgery. The treatment goals and physical evaluation of a patient with sleep apnea and snoring is critical and should set the foundation for the preoperative decision making, what procedures to consider, and the postoperative management.