A 57
A 57
A 57
Behavior modification is important, especially with regard to avoiding driving while drowsy and
need for significant weight loss. Pharmacologic treatment of OSAS is limited but may occasionally
include the use of stimulants to treat the symptoms of daytime somnolence. Medical devices are the
mainstay of therapy for adults with OSAS, especially patients with moderate to severe disease.
Continuous positive airway pressure (CPAP) and bilevel positive airway pressure serve as an airway
dilator or splint effectively eliminating pharyngeal collapse and resultant OSA for almost all patients. The
amount of positive pressure, reported in centimeters of water (cm H2O), is titrated in the sleep
laboratory or occasionally through self-titrating devices. Effectiveness of therapy is dependent on nightly
adherence to therapy, with some patients unwilling or unable to comply with treatment. Because of the
effectiveness of CPAP therapy, repeated efforts are made to optimize therapy for those having difficulty
adjusting to sleeping with a mask over their nose or face. Oral appliances designed to pull the tongue or
jaw forward may be effective for some patients with mild or moderate OSA who are unable to tolerate
CPAP. Custom-fit to minimize dental occlusion or temporomandibular joint symptoms is important.
Repeat polysomnography with the device in place is necessary to confirm improvement in OSA.
◆ Surgical Management
Surgical management of adult patients with OSAS is challenging. Tracheotomy can be curative
but is associated with significant complications and is not accepted by most patients. It may be
necessary in morbidly obese patients (BMI 40) with OSAS or obesity hypoventilation syndrome who
cannot tolerate or do not benefit from CPAP. Adenotonsillectomy is curative in most small children with
OSA, but its utility in adults is limited to young, thin patients with significant tonsil hypertrophy (3–4).
Uvulopalatopharyngoplasty (UP3), often performed with tonsillectomy, is effective for the minority (5%)
of adult OSA patients with isolated palate obstruction and tonsil hypertrophy (Fujita type I and Friedman
stage I), with success rates of 80 to 90% in this highly selected subset of patients making it an attractive
first-line therapy. Success rates are more modest (40%) in unselected patients or in patients with
apparent isolated palatal obstruction but without significant tonsil hypertrophy. UP3 in this group of
patients is reserved for those unwilling or unable to undergo CPAP. Success rates are much worse (5–
10%) in patients with morbid obesity or and multilevel (tongue and palate) obstruction. Unfortunately,
the latter group makes up around 80% of adult patients with OSAS. The primary goal of UP3 is not to
shorten the soft palate but rather to advance it anteriorly to open the velopharyngeal-retropalatal
airway. Preservation of all palatal musculature and posterior soft palatal mucosa will minimize the risk of
development of velopharyngeal insufficiency or nasopharyngeal stenosis. Because of the limited
effectiveness of isolated palate surgery for most adult patients with OSA, multiple procedures to address
hypopharyngeal collapse have been developed. The two most effective are often combined and include
an anterior mandibular osteotomy with genioglossus muscle advancement along with a hyoid
suspension to the mandible or thyroid cartilage. When performed in conjunction with UP3, these
procedures are considered phase I surgery by the Stanford protocol and are associated with success
rates of 60 to 70% of adult OSA patients. In attempt to reduce the morbidity of genioglossus muscle
advancement with mandibular osteotomy, other procedures have been developed with varying degrees
of invasiveness and effectiveness. Tongue suspension with a suture secured to the mandible avoids the
osteotomy and may be helpful for some patients, especially those with tongue collapse without
macroglossia. Midline partial glossectomy may reduce excess tissue in the base of tongue and help some
patients. Radiofrequency therapy to the tongue base can reduce tissue volume with minimal morbidity
and can be performed in the office with the patient under local anesthesia, but it requires multiple
treatments to be effective. Bilateral mandibular and maxillary advancement is considered phase II
surgery in the Stanford protocol and is successful in about 90% of patients who were not cured with
multilevel phase I surgery described above. The acceptance of this procedure is limited by the
requirement for multiple osteotomies and impact on dental occlusion. This may be considered firstline
therapy, however, for OSA patients with severe midface or mandibular hypoplasia. Bariatric surgery
involving gastric bypass is effective in morbidly obese patients (BMI 35–40) with severe OSAS who are
unable to tolerate CPAP or who are unaided by it. The effectiveness of bariatric surgery for OSA depends
on the weight loss achieved, often necessitating more than 100 lb in this group. Temporary tracheotomy
may be necessary until adequate weight loss is achieved.