In most patients, symptoms are successfully treated without surgical intervention through the use of microfluidic positive airway pressure (CPAP), mandibular advancement devices, weight loss, positional therapy, or upper airway exercises. However, in situations where these measures cannot bring restful nights or symptom resolution, we reach a crossroads where it is challenging to decide whether to proceed with surgical intervention.
Defining Failure of Non-Surgical Options
Failure to comply with CPAP because of discomfort, difficulty with isobaric pressure adjustment, and collapsing of the airway despite ideal pressure, as well as intolerance of oral appliances, usually elicits a referral to surgical intervention. Before recommending surgery, I probe three crucial areas:
- Anatomical Contributors – Anatomical Contributors are the obstructions in the airway located in a position that can be effectively addressed surgically, such as a recessed jaw (retrognathia), large tonsils, or floppy soft palate segments.
- Patient Factors – Is the patient comorbid (cardiac, risk of bleeding, anatomy that complicates healing), or is the airway anatomy predisposed to increase surgical risk?
- Previous Therapy Response – have we done device adjustment, mask fitting, options on alternative interfaces, or adjunctive therapies (e.g., myofunctional therapy, nasal steroid sprays)? Otherwise, they will have to wear out completely.
The Subtle Art of Patient Selection
Patient selection is the cornerstone of the success of surgery. Obstruction is localized with the aid of imaging (cephalometry, CT scan, sleep endoscopy). As an example, depending on the location of the collapsing point—established under general anesthesia endoscopically with drug-induced sleep (DISE)—a patient might undergo surgery to relieve the foreground obstruction in the most commonly affected areas, the epiglottic areas. In turn, less satisfactory outcomes can be present in patients with multi-level collapse or generalized tissue laxity.
I also stress that shared decision-making exists: Surgery is not a resort of last resort; it is a very precise weapon that acts in situations where the definite anatomical problems to conservative therapy are not remedied.
Common Surgical Options and Their Roles
- Uvulopalatopharyngoplasty (UPPP) – Effective when the palate/tonsillar area is most affected: poorer with great tongue base collapse.
- Genioglossus Advancement / Hyoid Suspension – Provides benefit when tongue base or hypopharyngeal collapse is primary.
- Maxillomandibular Advancement (MMA) is one of the most effective surgical procedures, effectively applied in cases of obstructive sleep apnea and when the patient is affected by retrognathia.
- Hypoglossal Nerve Stimulation – This method is used on patients who do not tolerate implants, yet have an appropriate anatomy and who do not experience multi-level collapse.
What Patients Must Know
- Realistic Expectations – Even effective surgery does not always mean that you will not require additional therapy.
- Risks and Recovery – Pain, bleeding, voice changes, or swallowing discomfort are possible and should be outlined transparently.
- Long-Term Evaluation – Postoperative sleep studies remain essential to verify improvement in apnea-hypopnea index (AHI) and reduction in end-organ consequences.
Surgery may provide meaningful, even life-changing, benefits when the non-surgical options fail, or an anatomical assessment shows an obstruction to be highly specific and is likely to respond to surgical intervention. However, it is not a default follow-up, but is a reasoned reaction based on anatomy, patient situation, and history of responding to therapy. A subtle assessment, joint determination, and plausible goal-setting will be the basis of the way ahead. For further insights on tailored sleep apnea treatments and surgical evaluation, see https://drkhliment.com.sg/sleep-apnea-singapore-treatment-surgery/.
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