Not all sleep apnea can be operated on. Surgery is only considered if you are not a candidate for a ventilator.
Is surgery the recommended treatment for sleep apnea?
Surgery is not the preferred treatment. Surgery is only considered for patients who are not suitable for a ventilator. Surgery can be considered for patients who are young, have no contraindications to surgery, have no complications due to chronic sleep apnea, and are evaluated by the surgeon to be curable after surgery. In some severe cases, if the doctor assesses that the condition can only improve after surgery, he is advised to wear a ventilator for a trial period and to have surgery only if he cannot receive a ventilator.
How to assess whether a patient is suitable for surgery?
First, patients with tonsillar hypertrophy visible when opening the mouth, and patients with significant anatomical narrowing of the airway cross-section found by endoscopy.
Second, the ability to perform surgery is monitored for the severity of the apnea: this includes the minimum oxygen saturation, the duration and frequency of the apnea, and then a comprehensive assessment is performed. In general, the milder the patient, the more suitable the surgery. Because there is a limit to how much surgery can alter the airway, if the patient’s apnea has become so severe that surgery cannot completely eliminate it, such as only eliminating apnea in the side-lying position and not in the supine position; only eliminating apnea in light sleep and not in deep sleep when the muscles are more relaxed, such patients will have only partial efficacy. The patient’s request for a change in subjective symptoms is also important. Each person has a different tolerance level for apnea, and some people will wake up with even one apnea all night. If the patient requires that all apneas must be completely eliminated, the procedure needs to be evaluated to see if it can be done. The degree of modifiability of the airway and the severity of the condition should be considered together.
Third, it will not cause surgical complications. Surgical procedures have to consider whether the anatomy can take on the necessary functions of the body and whether the bone structure can heal again, etc.
What is the effect of surgical treatment? Is it curable?
Some patients can be cured, especially those in the early stages. For example, the results of tonsil and adenoid surgery in children are very good, and almost 90% of them can be cured. This is because the bone structure of children is still developing and there are no secondary disorders such as central hypoxia. There are also some young patients with more severe structural changes but less severe central hypoxia, which may be cured.
Is it easy to relapse after surgery?
Sleep apnea is a long-term chronic disease and must be managed with a long-term concept. Seventy to eighty percent of the causes of structural changes in the airway are obesity, and only a small percentage of the factors are muscle relaxation due to aging. Surgery is usually overkill, for example, the airway will not close if it is enlarged by one centimeter, but it may be enlarged by two centimeters if the function allows, even if the muscle is a little more relaxed the airway will not close. The decline in muscle function that comes with aging is relatively slow, but if you become more obese after surgery, the likelihood of recurrence is high. This is why it is important to control weight after surgery, as it is very important to maintain the efficacy of the surgery. If weight control is not guaranteed, then the surgery should not be done.
What is the likelihood of recurrence if the weight is well controlled?
For patients who are cured, that is, patients who are able to return to near normal after surgery and who have strict weight control, the likelihood of recurrence is very small; for patients who are partially cured, that is, patients who still have some residual apnea after surgery and who cannot control their weight well or who have a combination of bony structural stenosis, the likelihood of recurrence is high.
How long does it take for a recurrence to occur?
If you do not control your weight after surgery, you may have a recurrence in about three to five years.
Can I have another surgery after a recurrence?
It is usually difficult unless a more extensive surgery is done. It is important to review regularly after surgery and to put the ventilator on as soon as there is a slight tendency of recurrence. Since the airway has been changed, the symptoms will easily improve with some lifestyle adjustments and weight loss.
Which is better, surgery or a ventilator?
The effect of wearing a ventilator is very immediate and can be seen immediately. Surgery requires a recovery period of about six months for the results to stabilize, at which point it is possible to evaluate whether the patient is completely cured. Generally, patients need to come for review one month, three months and six months after surgery, and according to each review, we will consider whether to perform respiratory interventions, and after six months, we will perform sleep monitoring, and only then we can evaluate the effectiveness of the surgery. If it is for individuals, the effect of ventilator and surgery is different for different people.
Is sleep apnea usually a multi-location blockage or a single-location blockage? Will surgery be performed on multiple sites?
The structure of the pharyngeal cavity is surrounded by soft tissue on three sides, and only the section of the posterior pharyngeal wall is bony. When a person falls asleep, the muscles relax and the soft tissues collapse downward, blocking the airway. The core of the palatopharynx can be blocked from the top to the bottom, with a shorter blockage in light cases and a longer blockage in heavy cases. Multiple structures can be involved in airway obstruction, including the uvula, soft palate, tongue, and even structures below the tongue root. In terms of the cause of airway obstruction, hypertrophy of the soft palate can lead to obstruction, and if the bony structure is not good, the attachment point of the soft palate can also lead to obstruction. The same is true for the tongue, which also has both hypertrophy and a posterior point of attachment. Therefore, the causes of sleep apnea include soft airway blockage and bony airway blockage. Some patients have to address the soft palate, while others have to address both the soft palate and the tongue, and different procedures address different degrees and characteristics of apnea.
Why should a patient with low oxygen saturation not be operated?
Such patients usually have a longer duration of apnea. If the oxygen saturation is so low that it can only wake this patient up, it means that he has poor central regulation. Surgery cannot treat the central problem. Although the postoperative airway is open, the center cannot command the diaphragm and intercostal muscles to move, and the patient still cannot breathe. This both affects the surgical outcome and poses a risk to the surgery. Such patients need to wear a ventilator for a period of time first, usually three months to six months, preferably six months, to have surgery.
What tests should be done before surgery?
The first is polysomnography; the second is upper airway CT, which evaluates the entire upper airway structure, including the soft tissue and bony structures, to help choose the surgical approach. The upper airway CT scans the nasal cavity, pharyngeal cavity, and soft palate, and then performs a three-dimensional reconstruction of the scans to see where the reconstructed airway is narrowed and where the surgery is targeted: whether it is the soft palate or the tongue, whether the jaw should be moved, whether the bony structures of the hard palate are narrow, whether the tonsils should be removed, etc. The third is a fiberoptic laryngoscopy, which looks at the cross-sectional area of the pharyngeal cavity through a mirror. Another common test is esophageal manometry, which assesses the plane of airflow obstruction, whether it is upper or lower airway obstruction, nasopharyngeal plane obstruction or soft palate plane obstruction, to help choose the surgical approach.
Do I need to do this esophageal manometry after having an upper airway CT?
Esophageal manometry and upper airway CT have different roles. Esophageal manometry can determine more clearly which plane is obstructed, while CT can visualize which area is narrowed.
Surgical approach.
Palatopharyngoplasty with preservation of the uvula? Tonsil/adenoids surgery, cryo-plasma/radiofrequency ablation? Orthognathic surgery, nasal surgery.