Surgery for Adult Patients with Obstructive Sleep Apnoea: a Review for General Practitioners

CLINICAL

Surgery for adult patients with obstructive sleep apnoea: A review for general practitioners

Nga T Phan, Benjamin Wallwork, Benedict Panizza

Background bstructive sleep apnoea (OSA) is Selection of patients for a common disease that has an surgery by history and Obstructive sleep apnoea (OSA) is a O estimated prevalence of 24% examination complex disease process that involves in men and 9% in women.1 OSA is a The assessment should begin with a collapse of the upper airway during sleep complex disease process that involves thorough history to identify patients and subsequent reduction or cessation collapse of the upper airway during sleep with an increased risk of OSA.7 The of airflow. Continuous positive airway and subsequent reduction or cessation of examination should document weight, pressure (CPAP) is the primary treatment airflow.2 It is associated with a variety of height and body mass index (BMI), as for OSA and is the recommended first-line medical consequences, such as excessive obesity is an independent risk factor.7, 8 treatment for patients with moderate- daytime somnolence, neurocognitive The nose should be examined anteriorly to-severe forms of the disease. However, some patients are unable to tolerate CPAP impairment, cardiovascular disease and for septal deviations, spurs, perforations 3 or are unwilling to accept it as a form of reduced quality of life. The economic and hypertrophic inferior turbinates. permanent management. In these cases, costs are substantial as patients with OSA The oral cavity should be inspected surgical management aimed at addressing use more healthcare resources, and have for macroglossia, enlarged uvula, anatomical obstruction may be useful and greater risks of motor vehicle accidents hypertrophic tonsils and an elongated warranted. and work-related injuries.3 Interestingly, soft palate. The modified Mallampati one study estimated the total yearly classification system is a useful guide to Objective cost of treating OSA in Australia to be categorise the relative crowding of the approximately $657 million.4 oropharynx (Figure 1).7 Finally, the neck This article presents an overview of the Continuous positive airway pressure should be palpated for any masses. surgical options available for OSA. The (CPAP), generally administered through In the consulting room, review also describes a useful approach for the nose, is the primary treatment for otolaryngologists are able to perform selecting appropriate patients for surgery. OSA and is the recommended first-line flexible nasal endoscopy under local Discussion treatment for patients with moderate-to- anaesthesia to assess the upper severe forms of the disease.2,5 However, aerodigestive tract for potential sites of On the basis of an OSA model that some patients are unable to tolerate narrowing.7, 8 Flexible nasal endoscopy accounts for observed increased risk of CPAP because of mask discomfort, while enables clinicians to identify abnormalities stroke, cardiovascular disease and motor others cannot accept sleeping throughout such as nasal polyps, adenoid vehicle accidents, there is evidence to the night attached to a mechanical hypertrophy, lingual tonsillar hypertrophy, support that surgery is beneficial and cost- device.2 Objective data collected from tongue-base collapse, hypopharyngeal effective for patients with severe OSA who patients have shown a compliance constriction and laryngeal lesions. The are intolerant of CPAP. There are many rate with CPAP of <50%.6 In these use of a flexible nasoendoscopy assists surgical options available for OSA. cases, surgical management aimed at the surgeon with clinical diagnosis, addressing anatomical obstruction may be assessment, surgical planning and warranted. outcome assessment.9

574 REPRINTED FROM AFP VOL.45, NO.8, AUGUST 2016 © The Royal Australian College of General Practitioners 2016 SURGERY FOR OBSTRUCTIVE SLEEP APNOEA CLINICAL

nasopharyngeal incompetence and less post-operative pain.12 This is achieved by the creation of a reversible flap, whereby the uvula is pulled away from the pharyngeal wall and reflected back towards the soft palate, thus expanding the oropharyngeal space. For the management of OSA, results from UPF are comparable to those of UPPP.12 Figure 1. The modified Mallampati classification system Grade I allows full visibility of the soft palate, uvula and tonsils; grade II allows visibility of the hard and soft palates, uvula Procedures to improve tongue- and upper tonsils; grade III allows visibility of the hard and soft palates and base of uvula; grade IV allows visibility of the base and hypopharyngeal hard palate only obstruction Tongue-base, temperature-controlled radiofrequency and coblation Surgical options for OSA Procedures to improve retropalatal Tongue-base, temperature-controlled For patients who are deemed suitable obstruction radiofrequency is a procedure that involves for CPAP but unable to tolerate it, Uvulopalatopharyngoplasty the application of a temperature-controlled or for patients who are unwilling to Uvulopalatopharyngoplasty (UPPP) is a radiofrequency probe to multiple locations accept CPAP as a permanent form of procedure that removes the obstructing in the tongue base.7, 1 2 Radiofrequency management, surgery may be useful. tissues of the soft palate, lateral generates frictional heat that results in These patients should be referred to an pharyngeal walls and tonsils in order to tissue injury and volume reduction. Risks otolaryngologist for further assessment widen the pharyngeal airway.7, 1 2 There of the procedure include pain, infection, (Figure 2). Results from a study are various approaches to this procedure, swelling of the floor of the mouth, altered conducted in middle-aged men with including relocation pharyngoplasty, taste, tongue numbness and dysphagia.7 severe OSA who were intolerant of CPAP lateral pharyngoplasty, Z-palatoplasty and This procedure is currently performed only show that surgery is cost-effective.10 palatal advancement. UPPP is indicated as an adjunct to other hypopharyngeal This study was based on a model of OSA for patients with isolated retropalatal procedures as it rarely results in significant that accounted for observed increased obstruction; but unlike nasal surgery, it improvement when performed alone.12 risk of stroke, cardiovascular disease and is not recommended as a procedure to In cases where the lingual tonsil itself is motor vehicle accidents. OSA requires improve CPAP tolerance and compliance.7, 1 2 grossly enlarged, a reduction by coblation long-term, multidisciplinary management. On the contrary, UPPP results in large can be undertaken (Figure 3). Coblation Surgery may be offered to patients, oral leaks and decreased compliance with combines radiofrequency energy and saline depending on the severity of the disease CPAP.7 Thus, otolaryngologists must be to create a plasma field that ablates tissue and the patient’s anatomy, risk factors careful to limit palatal resection in patients while minimising damage to surrounding and preferences.11 The following section who may require CPAP following the areas.13 discusses the different surgical options procedure. Tongue-base suture suspension available for OSA. UPPP may be associated with significant complications including The tongue-base suture suspension Procedures to improve nasal velopharyngeal insufficiency, dysphagia procedure addresses obstruction in patency and breathing and nasopharyngeal stenosis.12 The overall the tongue base and hypopharynx.12 In Opening an obstructed nose will not success rate is around 40% with UPPP this procedure, a submucosal suture is improve OSA; however, it may improve surgery alone.12 anchored to the genial tubercle to prevent nasal breathing, CPAP tolerance and the tongue from collapsing and occluding Uvulopalatal flap compliance.12 Indeed, patients with the pharynx when muscle activity is reported symptoms of nasal obstruction, The uvulopalatal flap (UPF) is a modification reduced during sleep. The most common dryness or rhinorrhoea may benefit of the UPPP and carries similar risks.12 It risks associated with this procedure are from nasal surgery to improve CPAP is also indicated for patients with isolated infection, haematoma and dysphagia.7 The tolerance.7 Septoplasty, turbinate retropalatal obstruction. However, it is tongue-base suture suspension procedure reduction or both may be performed preferred to UPPP for most cases as it is generally considered to be minimally to establish nasal patency and airway provides the same anatomical results invasive, safe and effective. However, the stability. but is associated with a lower risk of success rate when performed alone for the

12 management of OSA is variable. Thus, it is Sleep disorder symptoms often performed in conjunction with UPPP to maximise outcomes.

Transoral robotic surgery for tongue- History and examination (including assessment of tonsil size) base reduction

While the nasal and oropharyngeal No Yes Evaluate for other Suspected OSA Sleep study regions are easily accessible, traditional causes of symptoms surgical approaches for OSA are limited by difficulties in accessing the tongue base No 14,15 Evaluate for other and hypopharynx. Transoral robotic OSA confirmed? disorders or pathology surgery (TORS) is a novel technique designed to overcome these limitations Yes by improving visualisation and surgical 15 Referral to sleep access to the tongue-base region. Studies physician have found that tongue-base resection with TORS is feasible and well-tolerated, with less risk of neurovascular injury Discuss treatment options and intraoperative bleeding.14 Whether (eg weight loss and mandibular performed alone or as part of a multi-level advancement splint for mild-to- moderate OSA) strategy for OSA, TORS has been shown to result in a significant reduction in daytime somnolence and the apnoea-hypopnoea Manage patient Accept or able to CPAP offered index (AHI).14,15 with CPAP tolerate CPAP

Posterior midline glossectomy Decline or unable This procedure involves resection of the to tolerate CPAP midline tongue base using carbon dioxide laser, radiofrequency ablation or robotic- assisted electrocautery.7, 1 2 The risks of the Referral to otolaryngologist procedure include bleeding, pain, increased secretions at the tongue base and altered Figure 2. Referral algorithm for OSA taste. The success rate is variable, ranging CPAP, continuous positive airway pressure; OSA, obstructive sleep apnoea from 25–83%.12

Genioglossus advancement In this procedure, the geniotubercle The success rate for the procedure is bleeding, infection and facial numbness.12 (with the genioglossus insertion) is variable, ranging from 23–77%. Thus, it is Traditionally, maxillomandibular moved forward without moving the generally performed with UPPP in order advancement is considered a second- mandible.12 At the geniotubercle, the to maximise outcomes.12 stage procedure, following soft tissue genioglossus muscle is attached to the surgery. However, it may be considered a Maxillomandibular advancement lingual surface of the mandible and the primary procedure in patients with obvious hyoid complex, just above the larynx. The Maxillomandibular advancement is craniofacial anomalies or multiple sites of forward movement of these structures currently the most effective surgical upper airway obstruction.7 stabilises the tongue base and associated procedure offered for OSA and has been pharyngeal dilators. The advancement shown to be as effective as CPAP.7,12,16 This Key messages for GPs places tension on the tongue musculature procedure specifically addresses tongue- OSA requires long-term, multidisciplinary and limits posterior displacement during base and hypopharyngeal obstruction, and management. Surgery may be offered sleep. The risks associated with the involves bilateral sagittal split of the ramus in carefully selected patients, depending procedure include infection, haematoma, and Le Fort I osteotomies in order to on the severity of the disease, and injury to the genioglossus muscle advance the maxilla and mandible.7, 1 2 It is the patient’s anatomy, risk factors and and paraesthesia of the lower teeth.12 an invasive procedure and the risks include preferences. Patients who are unable to

576 REPRINTED FROM AFP VOL.45, NO.8, AUGUST 2016 © The Royal Australian College of General Practitioners 2016 SURGERY FOR OBSTRUCTIVE SLEEP APNOEA CLINICAL

useful and warranted. These patients should be referred to an otolaryngologist for further assessment. In the past two decades, advances in sleep medicine and technology have enabled better recognition and surgical management of the disease in carefully selected patients.

Authors

A B Nga T Phan BPharm, MBBS, MPhil, Medical Officer, Department of Otolaryngology, Head and Neck Surgery, Princess Alexandra Hospital, Figure 3. Pre-operative (A) and intra-operative (B) views of lingual tonsil reduction by coblation Woolloongabba, Qld; Adjunct Lecturer, School of Pharmacy, The University of Queensland, Brisbane, Qld. [email protected] Benjamin Wallwork MBBS (Hons), FRACS, PhD, tolerate CPAP or those with craniofacial using the AHI.7 Patient-centred outcomes, Staff Specialist, Department of Otolaryngology, Head and Neck Surgery, Princess Alexandra anomalies, can be referred to an such as somnolence, quality of life and Hospital, Woolloongabba, Qld otolaryngologist for further assessment. improvement of comorbid conditions, are Benedict Panizza MBBS, MBA, FRACS, There are many surgical options available also useful.7 FACS, Chairman and Director, Department of Otolaryngology, Head and Neck Surgery, Princess for OSA and the decision on the most Alexandra Hospital, Woolloongabba, Qld; and appropriate intervention is based on Conclusion Associate Professor, School of Medicine, The University of Queensland, Brisbane, Qld anatomical considerations. Success rates CPAP is the primary treatment for OSA and Competing interests: None. for surgery are variable and the longevity is the recommended first-line treatment Provenance and peer review: Not commissioned, of benefit is uncertain (Table 1). Following for patients with moderate-to-severe externally peer reviewed. surgery, patients require ongoing follow- disease. However, for patients who are Acknowledgements up with their sleep physician, surgeon unable to tolerate CPAP or those who are The authors thank Associate Professor Stuart and general practitioner. Objective unwilling to accept CPAP as a permanent MacKay for providing the images seen in Figure 3 measurement of success can be reported form of management, surgery may be of the article.

Table 1. Summary of success rates for surgical treatment of OSA

Surgical treatment Success rate

Procedures to improve nasal patency Opening an obstructed nose will not improve OSA; however, it may improve nasal breathing, CPAP and breathing tolerance and compliance

Procedures to improve retropalatal obstruction Around 40% based on reduction of AHI and respiratory disturbance index (UPPP and UPF)

Procedures to improve tongue-base and hypopharyngeal obstruction

–– Tongue-base, temperature-controlled This procedure is currently performed only as an adjunct to other hypopharyngeal procedures as it radiofrequency alone rarely results in significant improvement when performed alone

–– Tongue-base suture suspension alone The success rate when performed alone is variable. The procedure is often performed in conjunction with the UPPP to maximise outcomes

–– TORS for tongue-base reduction Around 54% based on reduction of AHI and resolution of daytime somnolence as measured by the (alone or as part of multi-level strategy) Epworth Sleepiness Scale*

–– Posterior midline glossectomy Variable, 25–83%, based on reduction of AHI

–– Genioglossus advancement Variable, 23–77%, based on reduction of AHI

–– Maxillomandibular advancement Around 75–100% based on reduction of AHI†

*Success rate based on a study conducted by Lin et al (n = 39)15 †Success rate based on a study conducted by Lee et al (n = 35) and a review by Li et al17,18 AHI, apnoea-hypopnoea index; CPAP, continuous positive airway pressure; TORS, transoral robotic surgery; UPF, uvulopalatal flap; UPPP, uvulopalatopharyngoplasty

References 7. Smith DF, Cohen AP, Ishman SL. Surgical apnoea: A multi-centre Australian trial. J Clin 1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, management of OSA in adults. Chest Sleep Med 2013;9(2): Badr S. The occurrence of sleep-disordered 2015;147(6):1681–90. 117–24. breathing among middle-aged adults. N Engl J 8. Al-Hussaini A, Berry S. An evidence-based 14. Muderris T, Sevil E, Bercin S, Gul F, Kiris M. Med 1993;328(17):1230–35. approach to the management of snoring in adults. Transoral robotic lingual tonsillectomy in 2. Spicuzza L, Caruso D, Di Maria G. Obstructive Clin Otolaryngol 2015;40(2):79–85. adults: Preliminary results. Acta Otolaryngol sleep apnoea syndrome and its management. 9. Hsu PP, Tan BY, Chan YH, et al. 10th Yahya 2015;135(1):64–69. Ther Adv Chronic Dis 2015;6(5):273–85. Cohen Memorial Lecture: Clinical predictors 15. Lin HS, Rowley JA, Folbe AJ, Yoo GH, 3. Hirsch Allen AJ, Bansback N, Ayas NT. The effect in obstructive sleep apnoea patients with Badr MS, Chen W. Transoral robotic surgery for of OSA on work disability and work-related computer-assisted quantitative videoendoscopic treatment of obstructive sleep apnoea: Factors injuries. Chest 2015;147(5):1422–28. upper airway analysis. Ann Acad Med Singapore predicting surgical response. Laryngoscope 4. Deloitte Access Economics. Re-awakening 2005;34(11):703–11. 2015;125(4):1013–20. Australia: The economic cost of sleep 10. Tan KB, Toh ST, Guilleminault C, Holty JE. 16. Randerath W, Bauer M, Blau A, et al. Relevance of disorders in Australia. Blacktown, NSW: Sleep A cost-effectiveness analysis of surgery for non-CPAP treatment options in the therapy of the Health Foundation, 2011. Available at www. middle-aged men with severe obstructive sleep obstructive sleep apnoea syndrome. Somnologie sleephealthfoundation.org.au/pdfs/news/ apnoea intolerant of CPAP. J Clin Sleep Med 2006;10(2):67–98. Reawakening%20Australia.pdf [Accessed 2015;11(5):525–35. 1 7. Lee NR, Givens CD Jr, Wilson J, Robins RB. 14 March 2016]. 11. Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical Staged surgical treatment of obstructive sleep 5. Krishnan PV, Raghunandhan S, Anand Kumar RS, guideline for the evaluation, management and apnoea syndrome: A review of 35 patients. J Oral Kameswaran M. A rational approach to the long-term care of obstructive sleep apnoea in Maxillofac Surg 1999;57(4):382–85. management of obstructive sleep apnoea adults. J Clin Sleep Med 2009;5(3):263–76. 18. Li KK, Riley RW, Powell NB, Troell R, Guilleminault syndrome. Indian J Otolaryngol Head Neck Surg 12. Lefebvre E, Moreau R, editors. Snoring: Causes, C. Overview of phase II surgery for obstructive 2014;66(Suppl 1):138–46. diagnosis and treatment. New York: Nova Science sleep apnoea syndrome. Ear Nose Throat J 6. Kribbs NB, Pack AI, Kline LR, et al. Objective Publishers, 2010. 1999;78(11):851, 854–57. measurement of patterns of nasal CPAP use by 13. MacKay SG, Carney AS, Woods C, et al. Modified patients with obstructive sleep apnoea. Am Rev uvulopalatopharyngoplasty and coblation Respir Dis 1993;147(4):887–95. channelling of the tongue for obstructive sleep