Minimally Invasive Surgical Treatments for Obstructive Sleep Apnea

Criteria for Surgery

The mechanism that causes collapse of a patient’s airway will vary from one person to the next. Variables include age, body weight, anatomy, and body position. Thus, different findings will require different surgical techniques, and there is no one-size-fits-all surgery for OSA.¹¹

A thorough physical examination of the upper airway is important. Maurer recommends considering the use of videoendoscopy under sedation, which allows a view of the mechanism and site of obstruction, with pressure catheters inserted to collect data. This procedure was developed in the 1990s to improve the analysis of obstruction within the upper airway. Unfortunately, the data are unclear about whether this aids in the surgical outcome.¹¹ Powell stated that sleep endoscopy is currently considered investigational because medication-induced sleep may differ from natural sleep without medication.¹

Nasopharyngoscopy, using fiberoptics, and lateral cephalometric analysis have been used for several years as primary diagnostic tools for patients being considered for a surgical procedure for OSA. Some new imaging procedures (eg, 3-D imaging coupled with advanced software programs) have been developed that may be helpful to assess regions that are constricted as well as provide a more exact measurement of the airway from the nose to the larynx.¹

Risks and Complications of Surgery
The higher risk of anesthesia-related complications during or after surgery related to OSA is one reason that surgery is usually considered to be the third-line of treatment. Patients with OSA commonly have hypertension and other cardiovascular disease, which adds to the risk of anesthesia-related complications. Patients who have anatomical abnormalities of the jaw or portions of the upper airway will also be at a higher risk. Initial intubation and providing anesthesia during procedures may be more difficult for patients with these jaw or airway abnormalities. Postsurgical pain management with opioids contributes to the higher rate of apnea. After extubation, the incidence of apnea has been found to be higher in the population with OSA as well.¹⁷

A study published in 2001 used a case-control matched population methodology to examine patients who were undergoing elective surgeries for either hip or knee joint replacements. Significant differences in overall complication rates were found among the patients with OSA (n = 101) compared with those of the control group (n = 101). These differences were not related to the type of anesthesia, narcotic use after surgery, or the type of operation performed. The OSA group had a significantly higher number of patients who required higher flow rates of oxygen postoperatively and for a longer period. Serious complications, including the reintubation of 2 patients and unplanned intensive care unit (ICU) transfers, were noted in the patients with OSA (24%) compared with the control group (P = .004). The mean length of hospital stay was significantly longer for patients with OSA (6.8 + 2.8 days) compared with those in the control group (5.1 + 4.1 days, P = .007).¹⁸

The OSA group in the aforementioned study was divided into 2 types during this investigation: one group (n = 36) included patients undiagnosed with OSA until after their surgery (mean 1.8 years); the other group (n = 65) had a confirmed diagnosis at the time of surgery. All 36 in the first group and 32 from the second group with diagnosed OSA did not use CPAP therapy at home; a total of 68 patients (67.3%) who had not received therapy before the surgery. The 33 patients with diagnosed OSA (32.7%) who did use CPAP therapy before surgery had lower complication rates, including shorter hospital stays (6.0 + 2.1 days) compared with their counterparts with untreated OSA (7.2 + 3.1 days). The authors surmised that there might be a carryover protective effect at least for the first postoperative day.¹⁸

A retrospective study examined patients with OSA who had outpatient surgical procedures performed under either major regional anesthesia (central neuraxial) or general anesthesia. The study looked at the first outpatient surgical procedure for the patient with OSA following the diagnosis except for otorhinolaryngologic surgeries, which were excluded from the study. The 234 patients with OSA were then matched to the same number of control patients who had also had outpatient surgical procedures (excluding the otorhinolaryngologic procedures). The researchers noted a higher incidence of endotracheal intubation in the OSA group (79.9% vs 73.9% in the control group, P = .017).

The OSA group was less likely to have a laryngeal mask airway used during surgery for their airway management (5.1% vs 10.7% in the control group, P = .017). The only significantly different complication between the 2 groups was unplanned admissions to an ICU in the postoperative period (although numbers/percentages were not listed in the article). However, there was no difference in the overall unplanned hospital admission rate between the 2 groups. One limitation to this study was that the control group had not been tested for OSA, and therefore, it was possible that some in the control group might have had undiagnosed OSA.¹⁹