Sleep Apnea and Surgery
Even simple surgical procedures can be perilous for people who have sleep apnea, and surgery to correct sleep apnea is seldom completely successful. This article explains the risks of general surgery for people who have sleep apnea, and the potential of surgical procedures intended to correct sleep apnea.
Anesthesia and Sleep Apnea
It is all too common for people who have sleep apnea to stop breathing when they are under a general anesthetic. Typically the anesthesiologist will be prepared for this eventuality when surgical patients are morbidly obese, but not all people who have obstructive sleep apnea are obese. Undiagnosed central sleep apnea is an even greater risk factor during general surgery, because anything that reduces brain activity can also reduce muscle activity and breathing in people who have central sleep apnea.
Even if you only snore or have a tendency toward daytime sleepiness, be sure to let your surgeon and anesthesiologist know before you have surgery. Chances are that your anesthesiologist will ask you about snoring and daytime fatigue before surgery, but it is important to give honest answers.
Pain Killers and Sleep Apnea
People who have central sleep apnea are at special risk when they take painkillers, particularly medications that relieve pain by relaxing muscles. Avinza (time-released morphine), Oxycontin (oxycodone), and Vicodin (hydrocodone with acetaminophen) are never recommended for people who have sleep apnea and are especially dangerous with alcohol. Valium (diazepam), Librium (chlordiazepoxide), and benzodiazepine tranquilizers are dangerous when taken in excessive dosages. It is important that your pharmacist also knows that you have sleep apnea so your pharmacist can work with your doctor to prevent potentially fatal medication errors. Alcohol is not as dangerous as other central nervous system depressants, but it it should not be drunk in excess, and it should be avoided after dinner. If you feel you simply cannot function with these drugs, you should contact your doctor.
Surgical Procedures to Correct Obstructive Sleep Apnea
The first line of treatment for obstructive sleep apnea is CPAP, but the simple reality is that fewer than 50% of people who start CPAP continue to use their machines on a regular basis after the first 90 days. There is no surgical treatment for central sleep apnea. Surgery offers varying degrees of success in treating obstructive sleep apnea.
• “Electric knife” surgery involves the use of a heated needle to burn away tissue at the back of the mouth after injection of a shot of Novocaine. Each session costs up to $1000, and the procedure usually has to be repeated. Even after several treatments, only about 40% of patients experience any improvement in apnea.
• Hypopharangeal or tongue-base procedures remove lower mouth tissues that may be interfering with airflow. Reduction of the base of the tongue is usually attempted only after failure of a procedure called UPPP, described below.
• Injection snoreplasty is a day patient procedure that stiffens the palate by injecting a hardening agent. Patients are given local anesthesia, and sent home after the procedure. Most people who have the procedure say that the pain involved is comparable to a very sore throat. Pain typically lasts 3 or 4 days, and the palate is hard enough to stop snoring after 3 or 4 weeks. The procedure is successful for treating snoring about 90% of the time, but it may or may not have any affect on sleep apnea.
• Jaw surgery is only likely to be helpful in people who have congenital deformities of the jawbone that have caused snoring and/or sleep apnea since birth. Called maxomandibular advancement, this operation literally pulls mouth and jaw tissues forward to open up the throat. Recovery from the operation may take a full year, but nearly 90% of patients are free of sleep apnea once they heal. There is also a less extensive procedure called mandibular osteotomy with genioglossus advancement (MOGA) in which only the tongue is moved forward, but it is slightly less successful.
• Laser-Assisted Uvulaplasty (LAUP) removes all or most of the uvula and surrounding tissues. It is often helpful for snoring but it usually has little effect on obstructive sleep apnea. Because the procedure eliminates snoring, many recipients of the operation erroneously believe they are also cured of sleep apnea.
• Pillar implant surgery involves threading of polyester rods into the soft palate under local anesthesia. These rods make the palate harder so it does not slip into the throat. Data submitted to the US Food and Drug Administration report that the operation is successful about 35% of time and actually makes obstructive sleep apnea worse about 11% of the time. However, if the surgeon operates on both the tongue and palate together the success rate is about 75%. This procedure is recommended for sleep apnea patients who have an AHI score under 30.
• Somnoplasty is a simple procedure in which the doctor inserts an electric needle into the palate to encourage the growth of scar tissue to make the palate harder. It is only momentarily painless, and it is possible to return to school or work only an hour or two after the procedure is done. Most recipients of the technique do better for 3 to 6 months, but then need another treatment. Scar tissue can build up so that CPAP becomes complicated.
• Surgery for deviated septum, when indicated, is usually successful. A broken or torn septum (the tissue separating the nostrils) may close off one or both nostrils. Repair of the septum is typically an uncomplicated procedure, although it is very important to do any “nose exercises” recommended by the surgeon to make sure the septum heals properly.
• Surgery for nasal valve defects, when they exist, is also usually successful. The collapse of the nasal valve may cause the sides of the nostrils to fall in on each other. (If you can press against your cheeks with your index fingers and pull away from your nose with the results that you breathe much better, you may have nasal valve collapse.) Correcting these structural defects usually relieves snoring and sometimes relieves sleep apnea.
• Tonsillectomy removes inflamed and enlarged tonsils. This procedure sometimes relieves sleep apnea in children.
• Uvulectomy involves snipping the uvula, the pear shaped tissue hanging down from the back of the palate over the opening to the throat. When the uvula is unusually large, this may improve air flow into the throat.
• Uvulopalatopharyngoplasty (UPPP) involves removal of the uvula plus trimming of part of the soft palate to widen the air passage at the top of the throat. During recovery from the procedure, nighttime breathing is usually worse, and most doctors describe it as “50% effective about 50% of the time.” Nonetheless, it is the only surgical treatment for obstructive sleep apnea approved by the US Food and Drug Administration, despite the fact that many people who have the procedure have to go back to CPAP.
Surgery almost never cures obstructive sleep apnea, and most people who have surgery for sleep apnea have to go back on CPAP in one year or less. But since surgical procedures performed under local anesthesia are generally not dangerous for people who have sleep apnea, some will elect to seek short-term relief with surgical procedures.