Sleep Surgery

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Once the diagnosis of obstructive sleep apnea (OSA) is established, Stanford Sleep Surgery believes the patient should be included in deciding an adequate treatment strategy.

Non-surgical treatments include Continuous Positive Airway Pressure (CPAP), positional therapy, use of oral appliances, nasal resistors, oropharyngeal exercises, and behavioral measures, including weight loss when indicated, frequent physical exercise, avoidance of alcohol and sedative medication before bedtime.

Continuous positive airway pressure (CPAP) remains the primary treatment for most adults with obstructive sleep apnea, however some patients don’t accept or cannot tolerate it, or have primarily correctable upper airway anatomic problems that can be causing the obstruction.

For these cases the advances in upper airway surgical techniques and appropriated patient selection can offer a definitive solution for OSA. In other cases surgery can be part of a comprehensive approach, improving the severity of obstructive sleep apnea and/or making the use of CPAP or oral appliances more tolerable. Surgery aims to reduce anatomical obstruction in the nose, throat, tongue, or more commonly, a combination of all to maximize airway patency. In some cases, the facial bones are inadequately positioned, and a more extensive procedure may be necessary. The goal is not solely to cure OSA, but to reduce snoring and cardiovascular disease risk, to recover sleep quality and decrease neurocognitive symptoms resulting in overall improvement in quality of life.

Importantly, a detailed clinical and endoscopic - and in some cases radiologic evaluation - in conjunction with the sleep test will provide us with the available data to decide with the patient what is the best approach, in an individualized manner.

OSA generally has various anatomical causes with multiple potential levels of airway obstruction; therefore, many different surgical procedures have been developed for its treatment and usually yield better results than a single-level surgery.

DISE is a necessary tool nowadays in the armamentarium of the sleep surgeon, allowing thorough and targeted evaluation of dynamic pharyngeal obstruction in the sleeping patient.

As sedation is administered in a supine position, the surgeon places the distal chip-tip scope into the nose identifying the side with least obstruction for minimizing discomfort.

The scope is passed through the nose, above the inferior turbinate, and directly inferior to the middle turbinate and passed posteriorly until the nasopharynx is reached. From this position, the scope is positioned in a rostral view facing toward the larynx (voice box) to best visualize the velum as sedation is infused. After observation at the level of the velum is complete and the degree of obstruction is noted, the scope is passed distally to observe the airway at the level of the oropharynx.

Subsequently, the scope is passed to observe the tongue base and epiglottis. Observed findings are recorded. Additional measures that are annotated include:

A. Lowest O2 saturation

B. Improvement of desaturation with jaw thrust

C. Improvement of desaturation with mouth closure

Care should be taken by the endoscopist (surgeon) to note additional structures of interest, such as mass lesions of the upper aerodigestive tract, enlarged adenoids, or laryngeal pathologies such as subglottic stenosis.