Michael Morgenstern, MD
Follow me:

Michael Morgenstern, MD

About the author: Dr. Michael Morgenstern is double board certified in Neurology and Sleep Medicine and the founder of the American Sleep Apnea Society. He is the Director of the Morgenstern Medical in Lake Success, NY, where he treats patients with sleep disorders and other neurological conditions.
Michael Morgenstern, MD
Follow me:

OSA surgery before CPAP

I was recently talking to a group of patients at a rehabilitation center about obstructive sleep apnea (OSA). A staff member came over to  me afterwards and told me that after his diagnosis with OSA, he underwent OSA surgery. He said, “Dr. Morgenstern I am very happy that I did it. I just could not see myself using CPAP (continuous positive airway pressure) for the rest of my life.” He was very happy with his decision. The OSA surgery he had known as U-triple-P, UPPP or uvulopalatopharyngoplasty had cured his apnea. He didn’t experience any major side effects from the surgery except pain for several weeks. I was happy to hear that things worked out for him. However, I have also heard about negative outcomes from UPPP.  I wondered why surgery was the first step used to treat his apnea. CPAP could and probably  should have been tried first. The biggest issue with apnea surgery is that there is a small but clearly present danger of a catastrophic outcome.

Problems with OSA surgery

OSA surgery obstruction areas

Major areas for airway obstruction include 1 & 2 – in the nasal airway, 3 – behind the soft palate & 4- behind the tongue.

UPPP is the most commonly performed surgical procedure for sleep apnea. As the name suggests, they remove the uvula and up to 1.5 centimeters of the soft palate in addition to removing the tonsils and excess tissue in the neck. The chances of UPPP being successful is only around 50%. The reason for this is because it only addresses obstructions that take place around the soft palate area. But OSA often occurs because of obstructions higher up in the nasal cavity or lower down at the base of the tongue. (Of note, the sleep apnea surgery might eliminate snoring, but fail to alleviate OSA, so a post-operative sleep study is important.) What about side effects of the OSA surgery? Besides from post-operative pain, which is bad, a large review of over 3000 patients who underwent UPPP found serious complications in 1.5% of the patients (around 30/3000 patients) and about 7 patients died (0.2%) within 30 days of the surgery. That doesn’t account for non-serious complications. I have seen a few. Such as patients who commonly experience the unpleasant sensation of food traveling upwards through their nose when eating or drinking.  About 15% of patients have this outcome and nearly 40% of patients have other long-term side effects, like swallowing problems, voice changes, and persistent throat pain. More recent studies, suggest that updated surgical techniques and post operative care reduce the risk of mortality. However, they still acknowledge serious side effects in nearly 1% of patients.

Minimizing surgical risks

CPAP works more often than OSA surgery. It is also safer. Serious side effects with CPAP are extremely rare.   Surgery, on the other hand, has the risk of side effects. Serious side effects include death. Therefore, CPAP (and other treatments) should always be tried before resorting to surgery for OSA. CPAP is about 100% effective when it is tolerated. In individuals who cannot tolerate CPAP and whom alternative treatments have failed, the risks of OSA can outweigh those of surgery. Advances in surgical techniques for OSA and in post-operative care make surgery for sleep apnea a viable option in these patients. An experienced surgeon, in consultation with sleep medicine physicians can be helpful. Based on apnea severity and the location of obstruction, they can advise on the best type of OSA surgery.  UPPP works when the obstruction is behind the palate, but other surgeries may work better for different locations of obstructions. Additionally, UPPP may not be helpful in more severe cases of apnea as it may only alleviate some of the apnea. This might not be enough to reverse the symptoms and the long-term risks of the remaining sleep apnea. Surgical risk might also be reduced by choosing the right location for a surgery. If a patient is considered to have poor health or be at high risk for surgery then it might be safer to have the surgery in a hospital rather than an outpatient surgical center.

CPAP before surgery

Many people have came to me telling me they are considering OSA surgery or that they would prefer it to using CPAP. I usually try to convince them to try out CPAP first. They may have spoken to people like the staff member I spoke to at the rehab center who had great results. Unfortunately, they do not have the perspective of the thousands of individuals who have had surgery for OSA. If they did they would realize that a small but appreciable percent of individuals who have undergone surgery for OSA have suffered from side effects. They might conclude that they give CPAP a longer try prior to considering surgery.

References:

http://www.ncbi.nlm.nih.gov/pubmed/15091217
http://www.journalotohns.com/content/pdf/1916-0216-42-15.pdf

About the author: Dr. Michael Morgenstern is a board certified Neurologist, expert in Sleep Medicine and  founder of the American Sleep Apnea Society. He is Director of the Cedarhurst Sleep Center in Long Island, New York and also sees patients with neurologic conditions.