Nasal and Palatal Surgery for OSA

Nasal and Palatal Surgery for OSA

Peter D. O’Connor

Tucker Woodson

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.


NAO is a recognized contributor to SDB. Patients with NAO report a worse quality of life, increased fatigue, and decreased quantity and quality of sleep. Some studies have shown a link between NAO and OSA (11). Populationbased studies have identified chronic nocturnal nasal obstruction as being significantly more likely in individuals with SDB (12) and habitual snorers without OSA (13).

Treatments will vary depending on the pathologic findings and symptoms. Historically, the primary symptom warranting treatment was subjective nasal obstruction. The finding of such strong associations with SDB, or quality sleep, and OSA support that these are also symptoms related to nasal obstruction. Improvement in sleep quality is a major component of validated nasal treatment outcome questionnaires (nose scale). In large cohorts and randomized controlled trials, surgical therapy has been shown to significantly improve sleep architecture, subjective sleep quality, and daytime sleepiness. Studies also support that in most patients as an isolated treatment, nasal surgery does not affect the AHI. A patent nasal airway, however, has been significantly associated with patient’s favorable response to treatment. A higher nasal resistance and nasal obstruction appears to decrease the use of both nasal CPAP and oral appliances, and negatively affect surgical
outcomes. Use of objective data on nasal airflow is not yet common in the clinical setting. Treatments may include correction of a septal deviation, reduction in turbinate size, correcting nasal valve collapse, or removal of nasal polyps.

There are differences in the literature regarding daytime symptoms of NAO, measures of nasal resistance, and objective polysomnogram data. This is in part because nasal airflow is a complex phenomenon, and how patients perceive airflow can be quite variable at different times and from one another. The physiologic nasal cycle, controlled by the hypothalamus, alters nasal mucosa every few hours. Air entering the nasal passageway is affected by shape of turbinates, mucosal properties, and nasal cilia. The nasal mucosa, especially overlying the turbinates, has an extensive vascular bed. Expansion of the network of vessels can lead to obstruction from acute or chronic inflammation and significantly impact the level of nasal resistance.

An important distinction to consider is how nasal resistance during wakefulness compares to the resistance of the nose while lying supine during sleep. There is evidence that nasal resistance changes throughout the course of the night. Increases in nasal resistance are greater in OSA compared to non-OSA populations. Whether this is due to differences in physiology (such as vascular compliance) or anatomy of the upper airway are unknown.

Predicting how nasal obstruction will impact CPAP use is also difficult. A common complaint of patients is that they cannot tolerate their mask and may remove it during the night. Why this occurs despite a proper level of therapy is unclear. Many patients report NAO and some authors have reported an increase in nasal symptoms in certain patients after starting CPAP therapy (14).

Despite the lack of a clear understanding about the role NAO plays in SDB, it can be an important component of the overall treatment algorithm for patients. However, nasal surgery alone is not accepted as a primary treatment alone for OSA in part because a linear relationship between daytime symptoms and severity of SDB does not exist. Clinical examination for the presence of nasal obstruction remains important to rule out compromised airflow through the nasal cavity and nasopharynx.


Physicians currently utilize subjective surveys, visual examination with endoscopy, and computed tomography scans to help in diagnosing patients with NAO. Objective testing of the nasal airway has most commonly been done using acoustic rhinometry and rhinomanometry. Acoustic rhinometry, although still primarily used as a research tool, provides a volumetric measure of the nasal cavity (15, 16). The anatomic measurement is taken during a breathhold and does not provide direct data on the flow of air through the nose. Rhinomanometry measures nasal obstruction and changes in resistance by assessing pressure and nasal airflow together during normal breathing (15).

Other methods have been utilized but to a lesser degree. These include nasal spirometry, laser Doppler velocimetry, and forced oscillation rhinomanometry to better describe nasal airflow, resistance, and potential sources of obstruction (17, 18, 19, 20, 21, 22, 23). These tests have varied acceptance and are not always practical in the clinical setting, and studies reveal differing conclusions (21, 24). More recently, some investigators have begun using computational fluid dynamics to model nasal airflow (25, 26, 27, 28).

Nasal Breathing and Impact on Sleep

NAO likely contributes to upper airway resistance through both indirect and direct mechanisms. Humans should breathe through their nose when sleeping. Nasal airflow is an important factor for maintaining neural tone and the patency of the airway. Nasal obstruction is ultimately a subjective sensation processed in the brain from numerous neurophysiologic receptors.

Use of a topical anesthetic to decrease afferent stimuli from the nasal airway has been shown to increase pharyngeal resistance resulting in an increased number of respiratory events over the course of a night (29). Decreased nasal airway flow should similarly result in a reduction of nasal afferent reflexes and subsequent decrease in muscular tone. Optimizing nasal airflow to maximize this feedback is important.

Nasal obstruction may also lead to mouth opening. Oral cavity opening leads to posterior rotation of the tongue base and displacement of the hyoid bone (30). Vertical opening with inferior displacement of the hyoid and a decrease in the hyomandibular distance results. These movements place the musculature of the tongue and pharyngeal tissues into a mechanically disadvantaged position and lead to increased upper airway collapsibility and increased hypopharyngeal obstruction. Despite mouth opening, the soft palate and tongue may remain in close apposition even if nasal breathing continues.

Additional evidence of the importance of having and maintaining nasal airflow during sleep comes via the concept of a Starling resistor. The upper airway is a collapsible tube. The larynx in humans, unlike other mammals, has a more caudal position creating a greater distance with the soft tissues of the pharynx in between. The soft tissues of the pharynx are not directly surrounded by osseous structure and are capable of collapse. The flow of air through the pharynx is influenced by upstream, downstream, and luminal forces. Tissues at multiple levels can contribute to collapse with the nasal cavity and nasopharynx providing upstream resistance. The flow of air and maximum velocity, through the collapsible segment, is inversely proportional to the upstream resistance. Areas downstream are susceptible to collapse including the retropalatal and hypopharyngeal segments. Optimization of airflow through the pharynx is impacted by reducing resistance upstream in the nasal cavity and can be extended to the nasopharynx.




Prevalence (%)

Viner et al. (69)



Hoffstein and Szalai (70)



Deegan and McNicholas (71)



Vaidya et al. (72)



Tami et al. (73)



Rowley et al. (74)



Weighted average = 0.597 (95% CI = 0.497-0.696).

For patients who do present with a complaint of snoring, symptoms of OSA, or disease proven by polysomnogram, it is important to explore the presence of NAO. Patients may present with a variety of findings (Table 137.1) (septal deviation, polyposis, nasal valve collapse, concha bullosa, adenoid hypertrophy, turbinate hypertrophy, choanal atresia, neoplasm, case reports of skull base, and neoplastic lesions). Chronic rhinosinusitis, allergic rhinitis, turbinate hypertrophy, polyps, and nasal septal deviation may to some degree all cause NAO (17, 18, 25, 31). Surgical correction of an obstructing lesion is justified if there are corresponding daytime or functional symptoms or other concerns. The effect on breathing at night or the use of CPAP is less clear.

The nasal passage functions as a resistor to airflow with both dynamic and static components. The static tissues include the septum and the structural foundation of the nasal cavity and nasopharynx is the maxilla. The dynamic elements of the nasal airway include the internal and external nasal valves as well as the nasal mucosa. The internal nasal valve is the narrowest cross-sectional area of the upper airway. It can therefore have a significant impact on airflow and accounts for nearly two-thirds of the total upper airway resistance. The anatomic components which define the internal valve include the nasal septum medially, the upper lateral cartilage positioned superolateral, the anterior tip of the inferior turbinate, and the pyriform aperture inferiorly. Numerous procedures are available for improving the nasal valve function and include both grafting and suspension techniques. Recognizing the influence of the bony structures is also important because they provide the foundation for the nasal airway. To a lesser degree, the bony foundation may be modified in some patients with improvements in nasal airflow having been shown after maxillary expansion (32, 33).

Investigators have attempted to produce nasal obstruction to determine its impact on respiratory parameters during sleep. Sleep disturbance has been shown in the setting of acute nasal obstruction. Following artificial simulation of NAO with catheters and balloons, an increased number of respiratory events including apneas can be seen (34, 35). Some of the events include a significant increase in the number of oxygen desaturations. More recently, Friedman et al. (36) have shown that in patients with mild OSA (RDI < 15), nasal packing increased their RDI, duration of snoring, and oxygen desaturation index in the immediate postoperative period.

Nasal obstruction is also associated with poor quality sleep independent of respiratory parameters. Anecdotally, patients with symptomatic seasonal allergies or increased nasal congestion from an upper respiratory infection may present with increased complaints of snoring and CPAP intolerance during the exacerbations. Correction of chronic NAO has been shown to have a significant impact on improving quality of life and daytime somnolence measures (37, 38). These findings were independent of any changes in AHI during overnight polysomnograms. This supports the notion that using a measure like AHI alone to assess the impact of nasal surgery is potentially incorrect.

Nasal Surgery

When considering nasal surgery on patients with OSA or snoring, the general categories include septoplasty, valvuloplasty, and turbinoplasty. Preoperatively, it is beneficial to contrast and compare a patient’s perception of their breathing and how it correlates to physical exam findings. Knowledge about what CPAP interfaces have been tried and successful may also be beneficial. A patient with weak lower lateral cartilage and significant internal or external nasal valve collapse may do well with a nasal pillow mask if the interface stabilizes this area. Poorly fitting nasal masks can also be problematic if they cause impingement of the nasal vestibule or alar side wall. Surgical correction of increased nasal resistance can be beneficial for patients.

Most studies regarding the impact of nasal surgery on OSA have focused on septoplasty. Some authors have assessed this in combination with other procedures including turbinate reduction (37, 39), UPPP (40), and sinus surgeries. Extensive study and literature addressing the nasal valves can be found elsewhere in this text. Further research into the impact of nasal valve surgery on sleep and CPAP is needed.

The ability to relieve SDB via surgery has been more difficult to demonstrate because of the complex nature of SDB and multiple structures involved. Prospective studies have shown significant changes in subjective symptoms following nasal surgery despite no significant difference on sleep parameters, AHI, or oxygen desaturation (37, 41, 42). One study did show a significant difference in the degree of AHI and snoring after septoplasty with or without turbinoplasty (39). Another interesting finding has been that for some patients there may be an improved tolerance of CPAP or a decrease in overall pressure required to treat their OSA following nasal surgery (37, 43). This potentially could improve CPAP tolerance in patients where higher CPAP pressures are the suspected etiology for poor compliance.

The role of the nasal turbinates and the impact turbinoplasty has on OSA and snoring is another area that requires
further evaluation. The ability of the nasal passage to function as a resistor depends on the ability of the turbinates to react to stimuli and change vascular tone.

In a large systematic review of the literature, Batra et al. (44) evaluated the efficacy of surgery for symptomatic adult inferior turbinate hypertrophy resulting in NAO. The majority of the studies were level 4 or 5 evidence. Of the 96 studies which met inclusion criteria for their review, 93 studies (96.9%) reported data showing a positive benefit from surgery with subjective symptom improvement in 50% or greater patients. Three studies showed no change or negative benefit. The findings reported were regardless of surgical technique utilized. In 2001, Clement and White (45) published a report on trends in research on turbinate surgery over the past four decades. They indicated a greater emphasis on technology trends rather than patient benefits in the literature. Surgical techniques utilized included turbinectomy, laser surgery, thermal techniques with predominantly radio frequency ablation and coblation, and turbinoplasty including microdebridement. Today the thermal techniques, including radiofrequency ablation and coblation, and the submucosal resection techniques with microdebridement seem to be the preferred procedures. General consensus of which is better requires more research and depends to some degree on what the surgical goal is. Some authors have shown a greater long-term benefit with powered microdebridement versus coblation or radiofrequency turbinate reduction (46, 47, 48). How these surgeries impact sleep parameters is unclear.

Objective data were reported in several studies following surgery of the inferior turbinates (44). Nasal resistance measured by rhinomanometry was improved in 83% of the studies (10 of 12) where it was performed and nasal airflow measured by acoustic rhinometry was improved in 100% (14 of 14). Unfortunately, we do not yet have a predictive mechanism to measure NAO with great specificity to determine who will tolerate and respond to CPAP or may benefit from inferior turbinate reduction.

Over a dozen techniques have been described for reduction of the inferior turbinates (49). There are some reports showing good correlation between preoperative topical decongestant and post-radiofrequency ablation of the turbinates with a visual analog score for nasal obstruction. These results have not been tested with other techniques or the impact on sleep parameters or CPAP use. Although most surgical techniques demonstrate some benefit in nasal airflow postoperatively, the most reliable technique with both sustained subjective and objective benefits is unclear. Nasal surgery can also have a large placebo effect that influences subjective scores making more research critical for this area (50).

NAO and the presence of SDB often coexist. The data supporting an improvement in subjective symptoms, decreased CPAP pressure required after nasal surgery, and improved tolerance of CPAP do not consistently correlate to the severity of disease. A beneficial outcome from surgery could be defined as improvement in both objective and subjective measures of nasal airflow. This would include improvements in sleep and a response to CPAP for patients with SDB. However, objective measurements do not always correlate with the patient’s symptoms of nasal obstruction. This suggests something other than AHI and nasal airflow conductance as a link between SDB and subjective symptoms.


Upper airway obstruction and OSA may occur at multiple sites. The upper pharynx in the retropalatal airway is frequently a primary site of obstruction during sleep (1

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May 24, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Nasal and Palatal Surgery for OSA

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