Treatments for Obstructive Sleep Apnea

Surgeries to Treat OSA

Surgery as a treatment option has been extensively reviewed and meta-analyzed [70–78]. Surgery for the treatment of OSA includes tongue suspension [70,74], maxillomandibular advancement (MMA) [72,73,78], pharyngeal surgeries (eg, uvulopharyngopalatoplasty [UPPP]) [73], laser-assisted uvulopalatoplasty (LAUP) [73], radiofrequency ablation (RFA) [73], tracheostomy [71], nasal surgery [75], and glossectomy [77], as well as multi-level and multi-phased procedures [70,74,76,77]. Most studies done on surgeries were case studies, with a minority of investigations that were randomized and controlled. Glossectomy, as part of a multi-level surgical approach, decreased AHI and symptoms of sleepiness, but glossectomy as a stand-alone surgical procedure did not improve AHI [77]. Significant improvements in AHI and sleepiness symptoms were seen in a majority of OSA patients who underwent MMA [72,73,78] and tracheostomy, although tracheostomy was performed for the morbidly obese or those who have failed other traditional surgical treatments [71]. Stand-alone tongue suspension and nasal surgery did not decrease AHI in the majority of patients, though nasal surgery did decrease subjective sleepiness [70,72,74,75]. However, tongue suspension combined with UPPP had better outcomes [70]. LAUP showed inconsistent results with the majority of studies showing no change in AHI, while UPPP and RFA seemed to improved AHI, although some studies showed no change [73]. Multi-level or multi-phase surgeries also showed improvements on OSA severity, but whether these surgeries are better than stand-alone remains to be investigated [73,76]. Morbidity and adverse events, like infection or pain, are common in all of these surgical events [70–78], but there are significant differences between the procedures. For example, MMA had fewer adverse events reported compared to UPPP [73]. More recently, glossectomy via transoral robotic surgery with UPPP [79] or epiglottoplasty [80] has been investigated; there were decreases in AHI, but response rates were between 64% to 73%. Although it seems surgical procedures to treat OSA are plausible, most studies were not rigorous enough to say this with any certainty.

Hypoglossal Nerve Stimulation

OSA subjects experience upper airway obstruction due to loss of genioglossus muscle activity during sleep. Without tongue activation, the negative pressure of breathing causes the upper airways to collapse [81]. Transcutaneous, intraoral, and intramuscular devices used to electrically activate the tongue have been developed and tested; however, although these devices decreased AHI they also induced arousals and sleep fragmentation caused by the electrical stimulus [82–86]. A new method had to be developed that would not be felt by the OSA patient.