Surgical Management

Surgical management also includes several options other than UPPP. Tracheotomy is an extremely effective surgical tool for the management of OSA. Although this technique provides an absolute solution to the problem, it is usually associated with both patient and physician resistance. In general, only the most severely affected patients with severe daytime somnolence or cardiovascular disease are offered this treatment option.

Nasal obstruction is often grouped with other traditional causes of OSA, and nasal surgery is often recommended as part of the treatment of patients who snore or who suffer OSA. The evidence to implicate nasal obstruction in the pathophysiology of this condition is minimal. One recent study that systemati cally evaluated the effects of surgical correction of nasal obstruction failed to demonstrate any meaningful postoperative reduction in sleep-disordered breathing in patients with OSA.20 Interestingly, several patients in this group had very mild apnea preoperatively and no other obvious upper airway structural abnormalities; among this patient group, the AHI normalized postoperatively. These findings suggest that nasal obstruction plays a role in only a small subpopulation of patients with mild OSA.

Recent excitement has accompanied the introduction of laser-assisted uvulopalatoplasty (LAUP). This procedure was initially introduced as an outpatient alternative for snoring, but its similarity to the widely used UPPP made it an enticing alternative for managing OSA. LAUP appears to be highly successful in decreasing or eliminating socially unacceptable snoring; however, there are limited data to support its use for OSA. Several recent studies have suggested that LAUP can improve OSA in certain mild cases of the disorder, among properly selected patients. Nevertheless, the efficacy of LAUP has not been established in this setting.21-24

Surgical procedures aimed primarily at the hypopharynx and tongue base have also been developed. Among these are the mandibular osteotomy/genioglossus advancement with hyoid myotomy/suspension (GAHM) and the more aggressive maxillary and mandibular osteotomies (MMO) with mandibular and midfacial advancement.4 These more invasive procedures may provide improved airway stabilization in selected cases; however, other than the studies provided by the Stanford University group, their effectiveness is unknown. Other more recent attempts to address the tongue base problem include various suture suspension and tongue base radiofrequency ablation techniques. Although theoretically sound, these newer procedures remain to prove their clinical efficacy.

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