Otolaryngol Clin N Am

40 (2007) 891–901

Success and Failure in Treatment

of Sleep Apnea Patients
Richard L. Goode, MDa,b,*
a
Department of OtolaryngologydHead and Neck Surgery, Stanford University
Medical Center, 801 Welch Road, Stanford, CA 94305, USA
b
Department of Veterans Affairs, Palo Alto Health Care System,
3801 Miranda Avenue, Palo Alto, CA, USA

Currently, there is no ideal surgical procedure for obstructive sleep apnea

(OSA), including the upper airway resistance syndrome (UARS). Surgical
treatment of snoring in adults without evidence of obstruction has greater
success; several reasonably successful effective procedures are available for
office treatment of snoring, providing improvement or cure for the majority
of patients treated. Although not yet ideal, they are closer to that goal than
the procedures available for OSA.

Snoring without obstructive sleep apnea

For snoring alone, the ideal operation should be one stage, performed in
the office under local anesthesia without sedation, and eliminate snoring in
90% or greater of cases. Furthermore, complications should be few and mi-
nor in nature. Postoperative pain should also be minimal and well-con-
trolled with the usual oral pain medications. Pain medication should be
required only for a few days. Because the procedure is not reimbursed by
the usual health insurance policies, the costs should be reasonable. With
an ideal operation, the results should be long-lasting, and any failures could
be retreated with the expectation of a similar high incidence of success. This
would bring the overall success rate to near 100%, a laudable goal. Uvulo-
palatoplasty (UPP) and uvulopalatopharyngoplasty (UPPP) are effective
operations to reduce or eliminate palatal snoring, but are usually done in
an operating room under general anesthesia to try and correct OSA

* Department of OtolaryngologydHead and Neck Surgery, Stanford University Medical

Center, 801 Welch Road, Stanford, CA 94305.
E-mail address: goode@stanford.edu

0030-6665/07/$ - see front matter. Published by Elsevier Inc.

doi:10.1016/j.otc.2007.04.006 oto.theclinics.com
892 GOODE

associated with the snoring. The uvulopalatal flap [1] is a variation that has
the potential to be reversed if needed; this reversal is rarely indicated.
In one review of eight studies of UPPP for snoring [2], 29.8% of patients
had no snoring and 43.1% had reduced snoring, for an overall ‘‘success’’
rate of 72.9%.
Procedures that come closest to achieving this ideal are discussed in the
following sections.

Soft palate tightening

Soft palate tightening procedures use radiofrequency (RF) energy deliv-
ered submucosally into several sites by a needle electrode [3].

Injection snoreplasty
This consists of injection of a sclerosing solution into the palate to
produce scarring and soft palate stiffening [4]. The resultant stiffening or
shortening of the palate prevents excessive vibration of the posterior edge
of the soft palate, thought to produce the snoring noise in the majority of
cases.
This procedure and the soft palate tightening procedure can be per-
formed in the office under local anesthesia, without the need for sedation.
Postoperative pain is usually mild and the complications minor. The cost
of palate injection is extremely low; the cost of RF treatment is higher,
and may require purchase of a disposable RF needle electrode, an additional
expense. In addition, an RF generator is needed, and this cost must be am-
ortized, adding to the expense. Over time, the effectiveness of the RF treat-
ment decreases, and it may need to be repeated; the same will probably
prove true for injection snoreplasty.

Uvulectomy
Uvulectomy in the office using an RF snare, standard cautery, or CO2
laser appears to be similarly effective, but has greater pain in the postoper-
ative period, lasting a week or more in most patients [5]. The same is true for
extended uvulectomy procedures, such as UPP, that remove more of the free
edge of the soft palate. These procedures may have the long-term complaint
of a feeling of ‘‘mucous’’ or dryness on the nasopharynx side of the palate
border; procedures that spare the free edge of the palate do not produce
this symptom.

Laser assisted uvulopalatoplasty

Laser assisted uvulopalatoplasty (LAUP) is a multistage office procedure
that requires a CO2 or equivalent laser, but does not need a new handpiece
for each treatment [6]. Because the cost of the laser must be considered, the
 TREATMENT OF SLEEP APNEA PATIENTS 893

expense of the procedure is necessarily higher than nonlaser procedures. The

associated pain is greater than with RF submucosal tightening, and the need
for multiple procedures is a deterrent. Some surgeons perform LAUP as
a one-stage procedure, which produces greater pain but eliminates the
need for multiple office visits.

Pillar procedure
Stiffening the soft palate by insertion of three or more small barbed im-
plants has been found to decrease snoring [7]. It can be performed quickly in
the office under local anesthesia. The major complication is postinsertion ex-
trusion. One disadvantage is the relatively high cost of the implants.

Other office surgical procedures

Other procedures designed to shorten and tighten the palate, such as the
cautery-assisted palatal stiffening operation (CAPSO), appear equally suc-
cessful for snoring [8]. All of these procedures seem to have some effective-
ness in the treatment of mild OSA and UARS caused by obstruction at the
palate level; over time, their success percentage decreases.

The role of nasal obstruction

It is unfortunate that opening an obstructed nose with standard nasal
procedures is not regularly effective in improving snoring, although it
should improve nasal breathing, including nocturnal nasal breathing.
There are several reports that show subjective improvement; a review of
eight papers found the average rate for cessation of snoring to be
41.9%, and reduction of snoring 85.3%, following correction of nasal
obstruction [2]. In patients who have nasal obstruction, whether just at
night or both day and night, opening the nose is appropriate, independent
of any effect on snoring. Assuming a straight nasal septum, a short trial of
a long-acting, topical, alpha adrenergic spray, such as oxymetolazine, at
bedtime to shrink the turbinates overnight will provide information to
the surgeon and the patient regarding the role of nasal obstruction in
producing snoring. If there is adequate snoring improvement, an office
procedure to decrease the size of the inferior turbinates can be performed.
Procedures to decrease the size of the turbinates can be performed at the
same time as procedures that tighten or shorten the soft palate. Submucosal
RF cautery to the turbinates to open the nose can be performed at the time
the soft palate is treated in the office, and is regularly effective [9]. Correction
of symptomatic nasal septal deflections is usually performed in an operating
room, commonly in combination with turbinate reduction. No information
exists on the effectiveness of this combination of nasal and palate surgery on
snoring or sleep apnea versus a soft palate procedure alone; however, it
894 GOODE

makes sense that opening an obstructed nose should make the patient feel
better.
A trial of a device to open the nasal valves at night can be used in the
same way as a nasal spray to shrink the turbinates. They can be used in com-
bination to determine if collapse of the valves, turbinate engorgement, or
both are contributing to nocturnal nasal obstruction, which results in
snoring.
Several devices are available, sold over the counter, to open the nasal
valves at night. Breathe Right strips (GlaxoSmithKline, Pittsburgh, Pennsyl-
vania) taped to the lower nose at night are the best known, and some data
indicate that they help [10]. Such devices can be used indefinitely, or an op-
eration to open the nasal valve area can be performed [11], either separately
or in combination with inferior turbinate reduction or septoplasty.

Evaluation of snoring
Unfortunately, the nature of snoring is such that it is almost impossible
for us to have hopes for an ideal snoring operation. There are three reasons
for this, two which we can address and attempt to solve; the third is more
difficult. The first is a diagnostic issue as to the exact site of the sound pro-
duced by the snorer. It is generally assumed that the majority of snoring
comes from vibration of the soft palate free edge. The data for this are
not as clear as we would like. Certainly, if the loud snoring that regularly
accompanies OSA and upper airway resistance syndrome (UARS) is caused
by the palate, it would appear logical that nocturnal airway obstruction has
the same cause. This is usually not the case, with the tongue base or hypo-
pharnx being a major component, with or without palate level obstruction.
The nose can produce noise at night because of narrowing, and possibly the
presence of thick mucus. This nasal snoring group are the patients whose
snoring improves with nasal surgery. In addition, nasal obstruction leads
to mouth breathing, and the presence of an open mouth during sleep in-
creases the sound intensity of the snoring. Although it is possible to snore
with the mouth shut, the sound levels achieved are not as great.
Some snorers snore during the exhalation stage rather than while inhaling,
and some snore on both inhalation and exhalation; the significance of this in
regard to treatment is unclear. Certainly, there are snorers in whom the
tongue is a component of the snoring noise, and this may be the sole compo-
nent after the palate has been shortened or tightened. Basically, our inability
to identify the site or sites of the snoring noise hampers our ability to provide
an appropriate operation. To operate on the palate of a snorer whose tongue
is the major reason for the snoring makes no sense, but is probably done all
the time.
The second problem is that even if we are sure that the snoring noise is
coming from soft palate vibration, we do not know how much palate re-
moval or tightening is required in a given case to totally eliminate the
 TREATMENT OF SLEEP APNEA PATIENTS 895

snoring. Because we do not want to produce velopharyngeal insufficiency

(VPI), there is a limit to what can be done to surgically correct snoring
from this site. This is common, as evidenced by the fact that snoring is
rarely completely eliminated after UPP.
We need better tests to determine the site of the snoring, so that the effect
of palatal stiffening or shortening can be evaluated before any surgery.
Acoustic analysis of the snoring sounds has been performed by several in-
vestigators to assess the site, but is not used routinely in the pretreatment
evaluation of snoring [12]. Many home and hospital-based polysomnogra-
phy systems include a measurement of the intensity and duration of snoring,
which is helpful but not enough. One method of home analysis, snoring and
apnea analysis (SNAP), claims to analyze the snoring sound so the sites of
the snoring can be determined using a proprietary algorithm [13]. It does
provide objective information on snoring duration, loudness, and frequency.
With practice, one can diagnose palatal snoring in the office by asking the
patient to produce a snoring sound. The low frequency ‘‘motorboat’’ noise
is distinctive when present. The presence of the bed partner during the exam-
ination is useful to confirm that the sound produced in the office is the same
as that during sleep (except possibly louder).
Another approach is the temporary immobilization of the free edge of the
palate and uvula, to validate the potential effectiveness of a palate procedure
in eliminating snoring. The simplest test is to temporarily attach the uvula
forward onto the soft palate, using a suture, to evaluate the effect on snoring
for 1 or 2 nights, releasing the temporary attachment after the evaluation.
The author and associates have used this technique on occasion to help
predict the effect of soft palatal tightening/resection on snoring; it could
be used to determine the effect on the respiratory disturbance index (RDI)
in cases of OSA. In this case, the temporary attachment would be performed
just before a nocturnal polysomnogram (PSG). More work is needed in this
area.
The third problem in achieving an ideal snoring operation is that the eval-
uation of the snoring result is done by the bed partner, so that no matter what
the objective data are, if the sleep partner says that snoring is still objection-
able, the operation is considered a failure. Although forms and visual analog
scales are available for the bed partner to fill out to analyze snoring, it is still
difficult to objectively evaluate ‘‘improvement’’ in snoring. Anyone who has
slept with a snorer knows it only takes two or three episodes to wake one up
in the middle of the night, become angry, and move out of the bed (or make
the snorer move out). There are few areas in surgery where the evaluation of
success or failure of a procedure is not by the patient, but by an individual
who the surgeon may not even know. What is the relationship between the
snorer and the sleep partner? Is it hostile? Is the sleep partner an insomniac
who wakes up at the slightest noise and then cannot go back to sleep? It is im-
portant that whenever possible, the surgeon meets the bed partner to assess the
relationship before any snoring surgery.
896 GOODE

Several nonsurgical snoring remedies are available. Three are mentioned:

Ear plugs. This solution is rarely effective, because the over-the-counter
ear plugs usually tried are either uncomfortable, ineffective, or prevent
awareness of important nocturnal sounds, such as a baby crying. Cus-
tom-fitted, deep, soft ear plugs are more likely to be successful.
Chin supports. Adjustable, elastic bands that go around the chin and vertex
of the skull have been available for many years as a treatment for snoring.
Termed ‘‘snoods,’’ they help by preventing the mouth from opening and
the jaw from falling back. Soft, orthopedic neck collars have been used
with some success to maintain mouth closure and an elevated chin,
thus reducing snoring (and OSA). An open nose is essential.
Dental devices hold the teeth together during sleep, and can also advance
the lower jaw forward. The most successful are those custom-fitted by
a dentist.

Obstructive sleep apnea

The diagnosis of OSA is made with a PSG, and treatment initiated using
nasal continuous positive airway pressure (CPAP). If CPAP cannot be tol-
erated, surgical treatment of OSA should be considered.
The problem of determination of sites of obstruction is a major issue in
the surgical treatment of OSA and UARS. Preoperative assessment in the
awake patient of the location of the obstruction during sleep is simply not
good enough at this time. Physical examination, Mallampati or Friedman
evaluation, lateral cephalometric radiographs, and fiberoptic endoscopy
with Mueller maneuver all have limitations as to determining the site or sites
of obstruction in a given patient. The OSA patient ideally needs to be eval-
uated during sleep.

Diagnosis of site
In the author’s opinion, the best objective test to determine the site of ob-
struction is multilevel pressure measurements during sleep [14]. This is not
routinely performed for a number of reasons. Sleep laboratories have no in-
centive to do such testing, because nasal CPAP corrects obstruction at all
levels; site of obstruction determination is of interest primarily to the sur-
geon. Current reimbursement schemes would need to be modified to pay
for such additional testing; sleep laboratories would need to be incentivised
by surgeons to perform such tests, or the surgeons would need to support
specialized testing systems that provide these data. Esophageal pressure
measurements during sleep have allowed us to diagnose UARS; a single
pressure measurement in the upper esophagus reflects the abnormally nega-
tive interthoracic pressure needed for inspiration during sleep. A similar test
using multilevel pressure sensors would provide us with a measurement of
obstruction at the palate and tongue base.
 TREATMENT OF SLEEP APNEA PATIENTS 897

The use of artificial sleep using intravenous medications while the sur-
geon looks at the potential areas of obstruction with a fiberoptic endoscope
(sleep endoscopy) is used routinely in several centers outside of the United
States. It is expensive and time-consuming, unless performed at the time
of surgery for OSA. This is not routinely done in the United States, and
there are questions as to whether sleep produced by intravenous drugs is
the same as normal sleep. Volume CT and MRI evaluations during artificial
sleep also have limitations, with cost and risks similar to sleep endoscopy.

Definition of successful treatment

‘‘Success’’ in surgical treatment is usually defined as meeting the criteria
used by Sher and colleagues in their 1996 review [15]: 50% improvement in
the RDI, with a decrease in the RDI to below 20, or the apnea index (AI) to
below 10. These objective criteria of success are less than ideal, because the
normal RDI is 5 or less.
We must keep in perspective, however, that although nasal CPAP is more
likely to come closer to the normal values, compliance and regular use is
a major problem. Is reaching an RDI of less than 10, 60% of the sleep
time better than reaching a RDI of less than 20, 100% of the sleep time?
The end result of eliminating excessive daytime sleepiness is determined
by the patient. This may not always correlate with the results of a PSG,
the standard to diagnose and quantitate OSA. How do we score a case in
which the PSG shows marked improvement of the sleep apnea, whereas
the patient reports no improvement, or may even claim he is worse? What
about the reverse, when the patient is delighted at how she feels, but the
PSG shows minimal change? Certainly, in explaining why some patients
do not feel much better despite improvement in the PSG, the answer is
that we have probably simply moved the patient from OSA to UARS, or
there is another cause of the excessive sleepiness.

Surgical treatment: suspected palate level

Uvulopalatopharyngoplasty
In adults, UPPP appears to an appropriate and successful operation for
the 25% or so of OSA cases in whom the obstruction is limited to the soft
palate level, assuming we know who these patients are. It should also help,
but to a lesser extent, the additional 25% of patients in whom the palate is
a contributor but not the sole cause of the OSA. The overall result yields the
40.7% ‘‘success rate’’ reported with UPPP surgery alone, using the criteria
described by Sher and colleagues [15]. By eliminating patients who on clin-
ical evaluation appeared to have retrolingual obstruction as the primary
cause (large tongue, retrognathia, small or absent tonsils), postsurgical
UPPP success was higher (52.3%) [15]. The opposite is also true: UPPP
in the suspected retrolingual group provides essentially no improvement
898 GOODE

in OSA. The morbidly obese (BMIO33) are not good UPPP candidates
either.
Sleep endoscopy should provide improved UPPP results, because it can
better identify the sole or significant soft palate etiology OSA patients
who are the best candidates. In general, this is true; however, the difference
is not as much as desired [16]. Why is this? Although the answer is not
totally clear, the author believes it is twofold: (1) analysis, even with this
excellent method, is still a work in progress, and (2) UPPP, as usually
performed, does not adequately correct palate obstruction in a sizeable per-
centage of cases. More aggressive approaches to palatal shortening may pro-
vide better postoperative results, but have longer recovery periods and are
more involved. These include palatal Z-plasty and transpalatal advancement
pharyngoplasty [17,18].
Combining preoperative sleep endoscopy or multilevel pressure measure-
ments to confirm a palatal site of obstruction and a more aggressive palate
shortening procedure should result in improved surgical results for OSA pa-
tients who have a palate cause. At this time, UPPP should not be the sole
surgical treatment for the usual case of OSAdit is not good enough.

Other palatal shortening/tightening procedures

The palatal procedures previously described for snoring can improve
(and even cure) OSA, particularly mild OSA. Overall, none stand out as
a routine procedure for the usual case of OSA. Several are definitely less
morbid than UPPP and can be done in the office, a major cost and conve-
nience advantage.

Tonsillectomy
In children, tonsillectomy and adenoidectomy have provided successful
treatment of OSA in the majority of patients, because the obstruction is usu-
ally caused by enlarged tonsils or adenoids [2]. In adults, the presence of
large tonsils makes it more likely that a UPPP and tonsillectomy will be
successful.

Surgical treatment: tongue base level suspected

These treatments are regularly combined with an UPPP, even when
tongue base obstruction is suspected as the primary cause. They are really
multilevel therapy.

Radiofrequency
The success of multiple RF treatments to the tongue base, in a review of
11 series, ranges from 20% to 83%, using the usual surgical success criteria
[19]. The usual number of insertions of the RF needle is four at one time,
750 J each site. Multiple sessions, weeks apart, are required. An average
of 5.5 sessions was required in one series to produce a success rate of
 TREATMENT OF SLEEP APNEA PATIENTS 899

46.7% [20]. This is not adequate for the amount of treatments required, in
the author’s opinion. Other RF protocols are being evaluated and show
promise.

Geniotubercle advancement
In combination with UPPP, geniotubercle advancement (GTA) produces
a success rate of 39% to 70% [19].

Hyoid suspension/advancement
Again, usually used in combination with UPPP, and in some series, GTA.
By itself (but with UPPP) it appears to provide little advantage over UPPP
alone in the author’s experience (17% success) [21]. Others have found bet-
ter results (53.3%) [22].The latter study used preoperative sleep endoscopy
to better define the sites of obstruction. When combined with a GTA, there
may be an advantage over a GTA alone, but this is not clear.

Suture suspension of the tongue (repose procedure)

Again, combined with UPPP, suture suspension of the tongue has a sim-
ilar success rate to GTA, with a success range of 20 to 57% in six reports
[19].

Maxillomandibular advancement
Maxillomandibular advancement (MMA), the current ‘‘gold standard’’
for OSA, has a success rate of 90% or greater [23], but it is technically de-
manding and has substantial morbidity and expense.

Tongue base resection (midline glossectomy)

These procedures can be effective, but have a high morbidity, particularly
pain and postoperative dysphagia. Results vary from 25% to 83% success
[19]. Removal of large lingual tonsils is a different matter, and can be an ef-
fective OSA treatment, particularly in children.

Tracheotomy
Still very effective, but hard to convince patients to accept the side effects.

Other
Bariatric surgery can be effective in reducing the RDI in grossly obese
patients. Mandibular distraction in children who have poor mandibular
development may be curative in selected cases. The use of a dental splint
to further advance the lower jaw after failure of a GTA, repose, or RF
tongue procedure may provide success after failure of the surgical proce-
dure [24].
900 GOODE

Summary
In summary, we are in need of better methods of diagnosing the sites of
obstruction before surgery, and also better surgical procedures and combi-
nations of procedures to provide successful outcomes of greater than 80%
with minimal morbidity. Procedures that correct retrolingual obstruction
are particularly needed. The author is optimistic that this will occur!

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