Surgical management of OSA in adults.

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Contemporary Reviews in Sleep Medicine

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Surgical Management of OSA in Adults David F. Smith, MD, PhD; Aliza P. Cohen, MA; and Stacey L. Ishman, MD, MPH

OSA is a common, often chronic, condition requiring long-term therapy. Given the prevalence of OSA, as well as its significant health-related sequelae, a range of medical and surgical treatments have been developed and used with varying success depending on individual anatomy and patient compliance. Although CPAP is the primary treatment, many patients cannot tolerate this treatment and require alternative therapies. In this clinical scenario, surgery is often warranted and useful. Surgical management is aimed at addressing obstruction in the nasal, retropalatal, and retroglossal/hypopharyngeal regions, and many patients have multiple levels of obstruction. This review presents a comprehensive overview of research findings on a wide spectrum of surgical approaches currently used by sleep clinicians when other therapeutic modalities fail to achieve positive outcomes.

CHEST 2015; 147(6):1681-1690

AHI 5 apnea-hypopnea index; DISE 5 drug-induced sleep endoscopy ; ERS 5 European Respiratory Society; HMS 5 hyoid myotomy and suspension; HNS 5 hypoglossal nerve stimulator; LAUP 5 laser-assisted uvuloplasty; MMA 5 maxillomandibular advancement; PMG 5 posterior midline glossectomy; QOL 5 quality of life; RCT 5 randomized controlled trial; UPPP 5 uvulopalatopharyngoplasty

ABBREVIATIONS:

OSA affects 2% to 4% of adults in the United States.1 Numerous studies have shown that if untreated, OSA can have serious and sometimes grave medical consequences. It is associated with an increased incidence of hypertension, myocardial infarction, and stroke as well as the onset of type 2 diabetes, neurocognitive deficits, and increased mortality.2-7 CPAP has long been the primary treatment modality for OSA, and a significant body of research indicates that effective treatment with CPAP can reverse the negative cardiac and neurocognitive consequences of untreated disease.8-10 Patients who fail this approach may benefit from oral appliances, Manuscript received August 22, 2014; revision accepted November 29, 2014. AFFILIATIONS: From the Division of Pediatric Otolaryngology–Head and Neck Surgery (Drs Smith and Ishman and Ms Cohen) and Division of Pulmonary Medicine (Dr Ishman), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; and Department of Otolaryngology– Head and Neck Surgery (Dr Ishman), University of Cincinnati College of Medicine, Cincinnati, OH. CORRESPONDENCE TO: Stacey L. Ishman, MD, MPH, Division of Pediatric Otolaryngology–Head and Neck Surgery and Division of

lifestyle changes such as weight loss, and various surgical interventions. Both inferior turbinate reduction and tonsillectomy are frequently used alone or in combination to improve CPAP utilization, and they have both been shown to reduce CPAP pressure requirements.11 Surgery may also be recommended with curative intent for patients with an obvious anatomic obstruction such as large palatine or lingual tonsils.1 In addition, surgery is used as a salvage procedure to improve OSA in patients who fail CPAP and/or other treatment measures. The aim of surgical management is to address obstruction in the nasal, retropalatal, and retroglossal/hypopharyngeal regions, and,

Pediatric Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 2018, Cincinnati, OH 45229; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-2078

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in many patients, multiple levels of obstruction are identified.12 Because the field of sleep surgery is relatively young, there is, however, a dearth of evidence-based literature supporting the efficacy of this approach. As is the case with most surgical specialties, ethical and pragmatic issues make randomized controlled trials (RCTs) difficult, and many published reports pertaining to sleep surgery are, therefore, case series and case-control studies. Additionally, because multilevel surgical procedures are ideally based upon individual anatomic findings, pooling of data are difficult. Despite these issues, evidence indicates that in patients who have not achieved optimal outcomes with CPAP therapy or those who have failed this approach, surgical management is warranted and useful. This review provides an overview of commonly used surgical procedures performed for the surgical management of appropriately chosen adults with OSA.

Identifying Surgical Candidates Overall assessment of the patient with OSA should include a thorough medical and surgical history along with vital statistics such as BP and BMI. This information is critical in identifying patients in whom undergoing anesthesia poses an increased risk. For those who are deemed at increased risk, the use of local anesthesia, with or without sedation, should be strongly considered and may affect the types of surgical procedures selected for the management of OSA.

TABLE 1

For patients who are considered appropriate surgical candidates, decisions regarding surgical therapy are based on anatomic considerations. Conducting a thorough physical examination is, thus, essential. Examination findings commonly associated with OSA (Table 1) include hypertrophic tonsils, macroglossia or hypertrophic lingual tonsils, redundant pharyngeal pillars, a crowded oropharynx, an elongated uvula, or a combination of these anatomic features.13 In addition, the modified Mallampati classification system (Fig 1) can also be used to further categorize the anatomy of the oral cavity. While imaging modalities have been explored, including plain films, sleep fluoroscopy, and cine MRI, the utility of these techniques is not yet understood. However, both awake nasopharyngoscopy and drug-induced sleep endoscopy (DISE) are typically used to identify the specific site of obstruction in each individual patient. Awake nasopharyngoscopy is particularly

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Evaluation for Adults With OSA

Anatomic Location

Findings

General physical characteristics

Skeletal/craniofacial abnormalities Obesity

Nose/nasal cavity

External deformity Nasal valve patency/collapse Septal position/deviation Turbinate hypertrophy Mucosal hypertrophy Nasal polyps Rhinorrhea/purulence

Oral cavity

Tongue size/position Trismus Dental health/crowding Scalloping of the tongue High-arched palate

Oropharynx

Palatal/uvular elongation Tonsil size Modified Mallampati score

Hypopharynx

Lateral wall collapse Epiglottis shape Retroversion of epiglottis Lingual tonsil hypertrophy Glossoptosis

Larynx

True vocal cord function Arytenoid location/dislocation

Neck

Choosing the Appropriate Surgical Intervention

] Recommended General Physical Examination

Enlarged neck circumference Altered position of landmarks (hyoid, thyroid)

useful in identifying abnormalities such as nasal polyps, adenoid hypertrophy, lingual tonsillar hypertrophy, and obstruction of the retroglossal area. Less common sites of obstruction in the larynx and trachea also can be identified, as can obstructive lesions of the pharynx or larynx. Most sleep surgeons also use DISE to better understand the pattern of upper airway collapse during sleep. This information, together with the physical examination findings, must be considered prior to deciding which surgical procedure or procedures should be used for a particular patient. Drug-Induced Sleep Endoscopy

First described in 1991,14 DISE was intended to more accurately diagnose the location of upper airway collapse during a sleep-like state and guide effective surgical

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TABLE 2

] VOTE Classification System Used to

Describe Airway Collapse During DISE

Components

Classification

Structures

V–Velum, including soft palate, uvula or lateral pharyngeal wall O–Oropharyngeal walls, including palatine tonsils and lateral wall tissue T–Tongue base E–Epiglottis

Degree of obstruction

0–No obstruction 1–Partial obstruction 2–Complete obstruction X–Not visualized

Configuration of collapse

Anteroposterior Lateral

Figure 1 – Modified Mallampati grading of the oropharynx. This is accomplished with the tongue in the neutral position within the oral cavity; the mouth is opened for examination of the palate. A, Class I allows a full view of the tonsillar pillar and uvula, as well as a full view of the hard and soft palates. B, In class II, a partial view of the pillars and uvula can be obtained, with a full view of the soft and hard palates. C, In class III, a partial view only of the soft palate, but a full view of the hard palate, is visible. D, In class IV, the hard palate is the only structure that can be visualized, while the soft palate is out of view. (Printed with permission from Glia Media.)

intervention. Although controversy still exists regarding the similarities between sedation and natural sleep, DISE is presently the most widespread tool used to evaluate upper airway collapse in adults with OSA; it can be performed either as an isolated procedure or in conjunction with other sleep surgery.15 DISE is currently recommended to determine the utility of oral appliance therapy for patients considered reasonable candidates, for patients who fail CPAP therapy, and for patients who have failed previous surgical therapy.15,16 Developed as a means to standardize the classification of obstruction observed during DISE, the VOTE system specifies grades for the degree of obstruction at the velum, oropharynx, tongue base, and epiglottis, as well as the type of collapse (Table 2).17 Limitations of DISE include variability in both operative technique and variability in classification, and there is currently no standardization of the anesthetic class and dosage used for sleep endoscopy. In addition, there is continued debate as to how effectively it approximates natural sleep. However, there is a higher likelihood of success reported in patients undergoing sleep endoscopy prior to upper airway surgery for OSA, despite the fact that there is not yet definitive data correlating surgical outcomes with the sites of obstruction determined during DISE.18

Concentric The VOTE Classification17 applies both a degree and configuration of collapse to four distinct regions of the upper airway. DISE 5 druginduced sleep endoscopy.

Surgical Management of OSA A list of common sleep surgery procedures used for the treatment of OSA is shown in Table 3. Prior to surgery, the practice parameters from the American Academy of Sleep Medicine recommend that patients who are deemed to be surgical candidates should be counseled regarding the complications and success rates of appropriate surgical techniques.19 Measurement of surgical success has routinely been reported using the apneahypopnea index (AHI) as the primary outcome measure; however, patient-centered outcomes such as sleepiness, quality of life (QOL), and amelioration of comorbid conditions are also increasingly being used.20-23 Nasal Surgery

The contribution of nasal obstruction to the development of OSA remains controversial. Several studies have investigated the role of nasal surgery with curative intent. These studies are based upon research which indicates that increased upper airway resistance from nasal obstruction during sleep can promote pharyngeal occlusion,24 as well as clinical reports that show that it can exacerbate snoring and OSA.25,26 Although nasal resistance reportedly worsens the symptoms of OSA, data demonstrating that nasal surgery alone can result in improvement or resolution of OSA are sparse.27 A 2013 review of outcomes after nasal surgery reported no improvement in AHI, but consistent improvement in



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TABLE 3

] Surgical Procedures Commonly Used for the Treatment of OSA

Category Nasal

Procedure Septoplasty Resection of inferior turbinates Rhinoplasty/nasal valve surgery

Oral/palatal

Tonsillectomy Uvulopalatopharyngoplasty Laser-assisted uvuloplasty Radiofrequency of soft palate Pillar implants

Hypopharyngeal

Radiofrequency ablation of the tongue Midline glossectomy Lingual tonsillectomy Tongue-base suspension Hyoid suspension Genioglossus advancement

Other

Maxillomandibular advancement Hypoglossal nerve stimulation Tracheostomy

subjective symptoms of OSA such as sleepiness and overall QOL.28,29 A single RCT that compared septoplasty (with or without turbinate reduction) and sham surgery found no significant decrease in AHI for either group; however, unlike patients who underwent sham surgery, those who underwent septoplasty showed an improvement in sleepiness.30 Fifteen percent of these patients were considered surgical successes, with an AHI , 15 events/h and at least a 50% reduction of AHI from baseline.30 Despite the previously mentioned findings, nasal obstruction has been identified as an important target in the treatment of OSA,25 especially as a means to improve CPAP utilization and reduce CPAP pressure requirements. Symptoms such as a subjective sensation of nasal obstruction, nasal dryness, rhinorrhea, or an inability to tolerate the CPAP mask could suggest that nasal surgery would be recommended to improve tolerance. Decreased CPAP tolerance has been associated with increased nasal obstruction at the level of the inferior turbinate,31 and septoplasty and inferior reduction, including radiofrequency ablation and turbinoplasty, have reportedly improved CPAP compliance.32 Postoperative bleeding is the most common complication after septoplasty; other risks associated with this procedure include septal hematoma, septal abscess, septal perforation, alterations in smell, and cerebrospinal fluid leak.33 1684 Contemporary Reviews in Sleep Medicine

Tonsillectomy

As with nasal surgery, tonsillectomy alone has been reported to improve CPAP compliance and reduce CPAP pressure levels in adults with tonsillar hypertrophy34,35; however, the extent to which tonsillar hypertrophy contributes to OSA in adults remains unclear. Research focusing on tonsillectomy as a curative procedure has demonstrated almost universal improvement in AHI, although many patients continue to have persistent OSA after surgery.12 Retrospective studies published in the 1980s have shown highly variable ranges of improvement (20%-100%) in the apnea index after tonsillectomy in adults.36-39 Two small case series (total n 5 18) of adults with severe OSA and tonsillar hypertrophy have reported surgical response rates (AHI , 20 and ⱖ 50% decrease) in 86% to 100% of patients.40,41 A study of tonsillectomy alone, which selected for patients with significant tonsillar hypertrophy (grade 3 or 4), found a surgical response rate of 74% (AHI , 20 and ⱖ 50% decrease).42 A 2011 review of the literature authored by an interdisciplinary European Respiratory Society (ERS) task force concluded that tonsillectomy alone should be recommended as a primary surgical treatment in patients carefully selected for tonsillar hypertrophy.12 The most common complication is postoperative hemorrhage (6%), but other risks of this procedure include dehydration, pain, hypoxia, fever, and infection.43 Palatal Procedures

Uvulopalatopharyngoplasty (UPPP) was introduced as a curative procedure and quickly became the most common surgical treatment of OSA in adults.44 This procedure traditionally involved removal of the uvula, a portion of the soft palate and tonsils, along with closure of the tonsillar pillars. Over time, however, various approaches have been introduced to address narrowing or collapse of the retropalatal region. These approaches include relocation pharyngoplasty,45 lateral pharyngoplasty or expansion sphincter pharyngoplasty,46 Z-palatoplasty,47 and palatal advancement.48 Although these approaches differ in their exact surgical technique, all of these palatal surgeries involve the resection or repositioning of the palatal tissues and pharyngeal walls to increase the dimension of the pharyngeal airway to reduce obstruction. The reported success rate of UPPP for OSA is highly variable, ranging from 16% to 83%.49 For the most part, this variability appears to reflect inconsistency in patient selection together with differing UPPP techniques.50,51 Two RCTs have compared UPPP to oral appliance

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therapy and lateral pharyngoplasty, respectively.52,53 The first reported QOL at baseline and after 1 year of treatment and found that both the UPPP and the oral appliance groups had improved QOL at 1 year; nevertheless, the UPPP group showed more improvement than the oral appliance group.52 This was true despite the fact that OSA was shown to normalize (AHI , 10 or apnea index , 5 events/h) in 78% of oral appliance patients and 51% of the UPPP cohort.54 Although the previously mentioned study had a small sample size (n 5 27), it found that the mean AHI did not improve for those who underwent UPPP with or without concomitant nasal surgery, but improved significantly in those who underwent lateral pharyngoplasty.53 These results may, however, be confounded in that, unlike the UPPP group, the lateral pharyngoplasty group had a significant decrease in BMI after surgery.53 Adults with additional areas of upper airway obstruction are best treated with site-specific, often multilevel surgery, which may or may not include UPPP. A staging system based on tonsil size, tongue-palate position, and BMI was developed to determine the likelihood for successful resolution of OSA after UPPP (Table 4).55 These authors found that resolution rates after UPPP were 80% for patients categorized as stage I, 40% for patients categorized as stage II, and only 8% for those categorized as stage III.55 A subsequent study used this staging system combined with DISE to evaluate the site of obstruction and found a 95% success rate (AHI , 20 events/h with ⱖ 50% reduction) for UPPP for patients categorized as stage I and II when no other level of obstruction was evident on DISE.49 Unlike tonsillectomy and nasal surgery, UPPP has not been recommended as a procedure to improve CPAP TABLE 4

Stage

] Friedman Clinical Staging System for Sleep-Disordered Breathing55 Friedman Palate Positiona

Tonsil Size

BMI, kg/m2

I

1, 2

3, 4

, 40

II

1, 2

0, 1, 2

, 40

3, 4

3, 4

, 40

III

3, 4

0, 1, 2

, 40

IV

Any

Any

. 40

Stage I includes patients in whom it is easy to see the posterior pharyngeal wall (palate position 1 or 2) combined with large tonsil size (3 or 4). Stage II includes patients in whom only the palate is visible (palate position 3 or 4) with large tonsil size (3 or 4) or those with palate position 1 or 2 and small tonsil size (1 or 2). Stage III includes those patients with a palate position 3 or 4 and small tonsil size (0, 1 or 2). Stage IV is any patient with a BMI . 40 kg/m2. a Friedman Palate Position is similar to modified Mallampati scoring as seen in Figure 1.

compliance. Patients diagnosed with OSA who previously underwent UPPP had decreased CPAP compliance and larger oral leaks at lower pressures than those who did not undergo UPPP.56 For this reason, many sleep surgeons are careful to limit palatal resection in patients who may need CPAP therapy after UPPP. Common short-term side effects of UPPP include swallowing difficulty, velopharyngeal insufficiency, nasal regurgitation, and taste disturbances.57 Failure of UPPP is likely associated with secondary sites of obstruction in the upper airway or changes in the flaccidity of the soft palate after this procedure.50 Associated longterm risks include failure to cure,50 decreased efficacy over time,58 and intolerance to CPAP use.12 A 30-day mortality rate of 0.2% has been reported.59 To reduce the morbidity associated with UPPP, several minimally invasive office-based procedures have been developed, including laser-assisted uvuloplasty (LAUP), radiofrequency to the palate, and palatal implants. LAUP is designed to shorten the uvula and tighten the soft palate. Two RCTs have looked at LAUP vs sham surgery and nonsurgical treatment, respectively.60,61 The first reported a significant decrease in mean AHI (19 to 15 events/h), but no changes in daytime sleepiness or QOL.60 In the second, no significant changes in sleepiness, QOL, or respiratory events were reported.61 Radiofrequency of the soft palate entails interstitial electrosurgical treatment intended to stiffen the tissue of the soft palate through scar formation, ultimately minimizing collapse. Three RCTs reported significantly reduced AHI in patients with mild to moderate OSA after multiple treatments, however, most patients continued to have mild OSA after treatment.12 The only randomized trial with a placebo control did not show a significant reduction in AHI.62 In light of this evidence, the ERS task force concluded that LAUP should not be recommended and that radiofrequency should be recommended only in carefully selected patients.12 Reported risks from radiofrequency of the soft palate have not shown any serious adverse events, and the most common include mucosal ulceration/erosion, blanching of the mucosa, fistula, and tissue sloughing.63 Palatal implant placement is performed by placing nonabsorbable woven polyethylene terephthalate implants into the soft palate to induce an inflammatory response in the surrounding tissue.12 Formation of a fibrous capsule around the implants further serves to stiffen the palate and decrease palatal movement.64 Two RCTs have compared palatal implants to placebo. Both reported a significant improvement in sleep-related



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QOL and found palatal implants to be superior to placebo.65,66 However, the multiinstitutional study found no significant change in AHI after palatal implant placement,65 whereas the single-institutional study66 found a significant reduction in AHI (24 to 16 events/h) for patients who received implants. Complications with this procedure include implant extrusion and improper placement,67 as well as other more minor complications including irritation, mucosal ulceration, and infection. Palatal implants are generally recommended only for nonobese patients with mild to moderate OSA and collapse confined to the palatal region.12 Determination of the appropriate outpatient palatal technique should be made with the patient’s input and include factors such as cost (generally higher with pillar implants), pain (generally low with pillar implants), and convenience as radiofrequency often requires more treatment encounters than pillar implants. Hypopharyngeal Surgery

After the introduction of UPPP, it was recognized that up to 60% of patients had persistent OSA subsequent to palatal surgery secondary to obstruction at the base of the tongue. To address retroglossal obstruction, a number of procedures were designed to reduce tissue at the base of the tongue or minimize tongue-base collapse; the most commonly used procedures are reviewed here. Tongue-Base Reduction Procedures: Tongue-base reduction procedures include radiofrequency ablation, partial midline glossectomy, lingualplasty, and lingual tonsillectomy. All of these procedures are intended to reduce the size of the tongue, thereby increasing the space between the posterior pharyngeal wall and the tongue base. They are commonly performed as a component of multilevel salvage surgery and are not routinely recommended as solo procedures, as they rarely result in cure when performed alone. Radiofrequency tissue ablation involves the application of a temperature-controlled radiofrequency probe to multiple locations in the base of the tongue; this intervention is intended to reduce tongue volume through scar tissue generation. A pilot study demonstrated a 17% reduction in soft tissue volume with a mean of 5.5 treatments in 18 patients who failed UPPP.68 In a multiinstitutional, prospective, nonrandomized study comparing radiofrequency ablation to CPAP, patients had similar scores after treatment on the Epworth sleepiness scale,


the SF-36 QOL survey, and the functional outcomes of sleep questionnaire; the radiofrequency group had a reduction in the AHI from a mean of 40.5 to 32.8 events/h and underwent a mean of 5.4 ⫾ 1.8 treatments.69 A multisite placebo-controlled RCT evaluated multilevel radiofrequency ablation of both the tongue base and palate and reported improvement in QOL but no significant difference in AHI between treatment groups.70 A review of 11 case series of radiofrequency ablation reported success rates ranging from 20% to 83% when isolated radiofrequency to the tongue base was carried out over multiple sessions.71 Overall, most studies show limited but statistically significant reductions in AHI and sleepiness along with improvement in QOL after treatment. The ERS task force recommended that radiofrequency ablation of the base of the tongue be considered only in nonobese or moderately obese patients with retrolingual obstruction who are intolerant to conservative treatment.12 Risks of this procedure include postoperative pain, infection of the tongue, perioperative and postoperative bleeding, swelling of the floor of mouth, altered taste, tongue numbness, and dysphagia.72 Posterior midline glossectomy (PMG) involves resection of the midline tongue base tissue, including tongue musculature. This procedure has been described using a number of techniques such as CO2 laser, radiofrequency ablation, and robotic-assisted electrocautery. A summary of five case series using PMG as a single treatment modality reported success rates ranging from 25% to 77%, with decreases in AHI ranging from 17 to 43 events/h.71 However, these series often involved patients who had previously failed UPPP, and, thus, typically reflect results that might be seen after staged multilevel surgery. Analysis of 11 patients who underwent PMG after UPPP showed that patients who improved after PMG were more likely to be more retrognathic and thinner when compared with nonresponders.73 Another study of PMG combined with UPPP reported a 50% response rate (ⱖ 50% reduction in AHI) in 59% of patients at 12 months after surgery.74 Postoperative complications from this procedure include bleeding, pain and discomfort of the tongue, increased secretions at the tongue base, and altered taste.74 Lingual tonsil hypertrophy has been recognized as an additional factor in hypopharyngeal collapse, and lingual tonsillectomy represents just 0.4% of all sleep surgery performed in the United States from 2001 through 2010.75 We were unable to identify studies reporting on the efficacy of this intervention as a solo procedure in adults; however, studies of lingual tonsillectomy in

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pediatric patients with OSA after adenotonsillectomy show significant improvements in AHI postoperatively.76 A single trial that looked at six adults with severe OSA who underwent uvulopalatal flap along with lingual tonsillectomy showed no significant improvement in the respiratory disturbance index.77 Complications associated with lingual tonsillectomy are similar to those for partial midline glossectomy, and primarily involve postoperative bleeding and pain. Tongue-Repositioning Procedures: Tongue-repositioning procedures comprise tongue suspension (including repose), hyoid myotomy and suspension (HMS), and genioglossal advancement. As with tongue-base reduction procedures, tongue-repositioning procedures are intended to increase the space between the posterior pharyngeal wall and the tongue base. They are also commonly performed as a component of multilevel salvage surgery. Tongue-base suspension is designed to stabilize the tongue and prevent retrolingual collapse by anchoring the tongue to the mandible with a permanent suture. When performed in combination with UPPP in 15 patients, the mean respiratory disturbance index decreased from 45 to 24 events/h; six patients (40%) were considered surgical successes (AHI , 20 events/h with ⱖ 50% reduction).78 A prospective randomized trial of 17 patients found that tongue suspension improved retroglossal airway collapse more than genioglossal advancement at 4 months after surgery; AHI was not reported.79 The most common risks associated with tongue suspension include infection, hematoma, dysphagia, and odynophagia.12 HMS uses permanent sutures to suspend the hyoid bone to the thyroid cartilage or mandible, thereby pulling the tongue anteriorly. When it is used as a single procedure, reported success rates range from 40% to 53%.12 An MRI evaluation of retroglossal airway dimensions after hyoid suspension reported no change in airway size for 14 patients with severe OSA (mean AHI 5 35 events/h), suggesting that HMS serves primarily to stabilize the base of tongue.80 As noted in the ERS task force review,12 three studies of HMS with UPPP in patients with a mean BMI ⱕ 30 reported success rates ranging from 52% to 78%. In view of these findings, the task force concluded that HMS can be recommended as an isolated procedure in selected patients and is a reasonable component of multilevel surgery for patients with retroglossal obstruction; however, they cautioned that success rates tend to decrease with increasing BMI and AHI.12 Risks of HMS include dysphagia, aspiration, hematoma, seroma, and infection.

Genioglossus advancement involves mobilization and advancement of the genial tubercle of the mandible, with limited osteotomy and fixation or forward movement of the lower anterior mandible and attached muscles. Sliding genioplasty is also used to move the genioglossus muscle forward by separating the lower anterior mandible and its attached muscles and plating it forward 10 to 15 mm. A review of four case series on the use of these interventions as solo procedures reports success rates varying from 39% to 78%.71 When combined with other interventions, usually UPPP and HMS, as a component of multilevel surgery, the pooled data (n 5 117) showed that the mean AHI decreased by 60%.12,71 Risks of these procedures include numbness of the chin and teeth (usually short-term), infection, seroma, and injury to the teeth or mandible. Maxillomandibular Advancement

Maxillomandibular advancement (MMA) is intended to widen the retroglossal and retropalatal airways and has been found to be as effective as CPAP.81 This procedure involves bilateral sagittal split ramus and LeFort I osteotomies to advance both the maxilla and mandible. MMA has been shown to enlarge posterior airway dimensions.82,83 Although it has traditionally been considered a second-stage procedure after soft tissue surgery, genioglossal advancement, and/or HMS, MMA is sometimes recommended as a primary procedure in patients with obvious craniofacial issues and multiple sites of upper airway obstruction. These patients should also fulfill clinicoradiologic criteria based on cephalometric measurements. A summary of 12 case series (n 5 298) reported success rates of 67% to 100%, with some variation in the definition of success (AHI , 10 events/h vs AHI , 20 events/h).12 Risks of MMA include malocclusion, facial numbness, cosmetic changes, difficulty swallowing, and prolonged recovery. Hypoglossal Nerve Stimulation

The hypoglossal nerve stimulator (HNS) was approved by the US Food and Drug Administration in 2014. It is an implantable stimulator that stimulates the hypoglossal nerve to the tongue during inhalation to keep the retroglossal airway open during sleep.84 The HNS is recommended for adults with moderate to severe sleep apnea (AHI . 20 but , 65 events/h) who do not have concentric collapse of the palate on DISE evaluation. In a study of 19 patients with OSA who were unable to tolerate CPAP, HNS resulted in a significant improvement in mean AHI (43 to 20 events/h), sleepiness, and QOL



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measures.85 A prospective trial (n 5 31) found that improvements in AHI and functional outcomes of sleep questionnaire scores persisted at 12 months.86 In a separate multicenter, prospective, single-group cohort study, upper airway stimulation has also been shown to result in significant improvements in both QOL measures and AHI in patients with OSA.87 Risks associated with this procedure include hypoglossal nerve injury, infection, and device failure or dislodgement. Tracheostomy

Tracheostomy is a highly effective option for the treatment of OSA, especially in patients who have failed previous therapies.88 Meta-analyses have demonstrated the utility of tracheostomy in decreasing AHI, improving QOL scores, and decreasing mortality in patients with OSA.75,89 Due to the risks and long-term care associated with this procedure, it is primarily indicated in patients with life-threatening OSA who cannot tolerate CPAP or fail surgical options, in selected patients who have exhausted other treatment options, and in those with morbid obesity. The risks of tracheostomy include some perioperative and acute postoperative complications such as bleeding, decannulation, hypoxemia, arrhythmias, and pneumothorax, as well as more subacute and long-term complications, such as wound infections, tracheitis, and tracheocutaneous fistula. Multilevel Surgery

Imaging and DISE evaluations have confirmed that OSA often involves multiple sites of collapse (ie, nose, retroglossal, or retropalatal areas in as many as 90% of patients).90 Multilevel surgery is currently the standard for adults presenting for salvage surgery after failing conservative treatment, especially CPAP. Most sleep surgeons are, therefore, combining the procedures based upon personalized anatomic information that is often gleaned through DISE. A large meta-analysis of mixed multilevel surgeries demonstrated a 66% success rate (50% reduction in AHI and a postoperative AHI , 20).91 The ERS task force recommends multilevel surgery as a salvage procedure after CPAP failure and notes that it is most effective for those younger than 60 years of age who have no significant comorbidities and a BMI , 30.12

Conclusions Given the prevalence of OSA and suboptimal compliance with CPAP, surgical management is warranted and useful in appropriately selected patients who fail CPAP or alternative therapies. Inferior turbinate reduction and 1688 Contemporary Reviews in Sleep Medicine

tonsillectomy have been shown to improve CPAP compliance. For patients with an anatomic obstruction such as large palatine or lingual tonsils, surgery may actually play a curative role, and DISE is currently the most widely used method to determine levels of obstruction. Additionally, multilevel surgery serves as a salvage procedure for patients in whom other approaches have been exhausted. It is particularly important to note that surgery should be patient-directed and address specific identified sites of collapse.

Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article.

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