Sleep Apenea Surgery: Soft Palate Surgery is rarely, if ever a first line treatment for sleep apnea.

There are only two first line treatments for Sleep Apnea, CPAP and Oral Appliances. CPAP is extremely effective but the majority of patients abandon CPAP use due to comfort issues. Oral Appliances are a first line treatment for mild to moderate sleep apnea and an alternative to CPAP for the 60% of patients who abandon CPAP and those who use CPAP but just want to experience a more comfortable alternative to CPAP.

Note: For the morbidly obese CPAP is still the best treatment, for younger thinner and healthier patients oral appliances are effective and easy to fit into busy lifestyles.

Surgery, especiall soft palate surgery used to be considered a first line of treatment for sleep apnea but dismal results and high morbidity have relegated soft palate surery to a secondary proceedure, at best.

There were several types of soft palate surgery but the grandfather of all was the UP3, UPPP surgery or Uvulopalatopharyngoplasty. This surgery was excruciatingly painful, had a high morbidity and was usually unsuccessful in treating sleep apnea. According to Wikipedia the risks of UP3 surgery include:

"One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP experienced a worsening of their breathing following UPPP.
Others have spoken of severe acid reflux.
After surgery, complications may include these:
Sleepiness and sleep apnea related to post-surgery medication
Swelling, infection and bleeding
A sore throat and/or difficulty swallowing
Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery.
Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
Patients who have had the uvula removed will become unable to correctly speak French or any other language that has a uvular 'r' phoneme."

All surgeries to the soft palate carry risk and are painful. The LAUP procedure or Laser Assisted Uvuloplasty was less painful than up3 but still very painful. There was less chance of scarrig that dangerously narrowed the airway as seen with UP3.

Somnoplasty of the soft palate was less painful but equally ineffective in treating sleep apnea. Somnoplasty is a procedure to consider in patients with soft palate snoring and no sleep apnea. Other surgical alternatives are snoreplasty and pillars which again are useful for snoring but minimally helpful for treating sleep apnea.

Tracheotomy is the grandfather of surgeries and allows patients to breathe thru their throats. It is very successful but most patients do not want a long term tracheotomy.

The majority of sleep apnea is caused by the base of the tongue obstructing the airway or pressing on the epiglottis that blocks the airway.

There are several procedures that can be done to either advance the tongue or make it smaller. Somnoplasty on the base of the tongue is probably the preferred surgery for most patients contemplating reducing tongue size.

MaxilloMandibular Advancement is probably the most successful sleep apnea surgery but is extensive surgery carring definite risks. I strongly recommentd that patients undergoing this rocedure avoid ENT's and Plastic Surgeons and utilize Oral Surgeons with extensive experience in this type of surgery. The dental background of Oral surgeons make themthe first choice. They frequently do these surgeries for orthodontic purposes and understand stomatognathic function.

PATIENTS CONTEMPLATING MAXILLOMANDIBULAR ADVANCEMENT SHOULD ALMOST ALWAYS GO THRU A TRIAL OF AN ORAL APPLIANCE TO DETERMINE THE BEST POSITION FOR THE JAWS AFTER THIS RADICAL SURGERY. THIS WILL PREVENT NEEDLESS SECONDARY SURGERIES.

Nasal surgery is frequently helpful but rarely is a cure for apnea when done alone. Correction of deviated septums and turbinate reduction offer greater comfort for most patients with obstructed breathing due to anatomical or allergic problems.

Nasal surgery is usually and ENT procedure but is frequently one by oral surgeons as well.

Pediatric patients with sleep apnea are usually candidates for removal of tonsils and adenoids. While effective at opening the pharyngeal airway newer research suggests that orthodontic widening of the hard palate should be done either before or after T&A procedures. Widening prior to surgery may reduce post-operative complications.

Sleep apnea is probably responsible for at least 80% of the cases ADD and ADHD in children. The earlier the airway obstructions are addressed the healthier it is for future development.

UPPP Failure and limited success at Cleveland Clinic. Is it time to Abandon UP3 surgery as pPrimary Apnea Treatment

An article "UTILITY OF UPPP IN OSA: THE CLEVELAND CLINIC EXPERIENCE by Lee-Iannotti JK, Bae CJ, Kominsky A, Alsheikhtaha Z reviews the results of UPPP (UP3) surgery on 28 patients who met study criteria from 250 charts reviewed.

These 28 patients unerwent Uvulopalatopharyngealplasty, with or without tonsilectomy and/or septoplasty. ONLY 2 PATIENTS (6.6%) WERE "CURED" HAVING AN AHI OF LESS THAN "5". THE STUDY STATES THAT THERE WAS A 43 % SUCCESS RATE. HOWEVER SUCCESS WAS DEFINED AS 50% REDUCTION AND AHI OF LESS THATN 20. THESE PATIENTS STILL HAD MILD TO MODERATE SLEEP APNEA!

THE STUDY REPORTED " Overall, there was a decrease in the overall AHI in all the patients undergoing surgery (mean AHI ± SD, 45.6 ± 29.2 pre-UPPP vs. 30.4 ± 26.1 post-UPPP, P = 0.019*.) Thirteen patients (43%) achieved a 50% or greater reduction
in the AHI and/or an AHI of 20 or less.

The study showed no reduction in CPAP pressures: " Of the patients requiring CPAP therapy post-UPPP, there was
no significant decrease in pressure requirements (mean CPAP pressure
± SD, 9.4 ± 0.5 pre-operatively vs. 9.1 ± 0.7 post-operatively, P = 0.35.)"

The authors concluded that: "UPPP achieved surgical success in 43% of our patients. Younger patients (< 40 years) with lower Friedman scores (≤ 2) seemed to have greater surgical success rates. BMI, neck circumference, tonsil-
lar size, severity of OSA and presence of retrognathia did not seem to be predictors of outcome.

EXCEPT FOR YOUNGER AGES AND LOWER TONGUE POSITION THERE WERE NO PREDICTORS OF POSITIVE SUCCESS. BASED ON THIS STUDY THE USE OF UPPP SURGERY IN ADULTS OVER 18 IS QUESTIONABLE AT BEST.

BOTH CPAP AND ORAL APPLIANCES ARE MUCH MORE SUCCESSFUL EVEN WHEN POOR CPAP COMPLIANCE IS CONSIDERED.

COMPARED TO SURGERY ORAL APPLIANCES ARE DEFINITIVELY A BETTER TREATMENT CHOICE. CPAP IS A SUPERIOR CHOICE IF IT IS USED ALL NIGHT ON A REGULAR BASIS.

ONE ADVANTAGE TO SURGERY IS THAT PATIENT COMPLIANCE IS A NON-ISSUE.