ABSTRACT
Compliance with therapy tends to be very good in the majority of these patients. Surgical therapy is similar to that for patients with moderate obstructive sleep
apnea syndrome (OSAS). However, most patients with severe sleep apnea are obese
and UPPP with tonsillectomy often fails to correct the diffuse airway narrowing
caused by fat deposition in and around the airway musculature. UPPP (with tonsil-
lectomy) might be offered to those CPAP-intolerant patients who are not obese and
have relatively isolated airway narrowing in the retropalatal and oropharyngeal
region. UPPP (with tonsillectomy) in combination with nasal surgery and a combi-
nation of retro-lingual airway enlarging procedures may also be considered for
patients who cannot tolerate CPAP or BiPAP in a manner similar to that described
for moderate OSAS patients. In addition to the retro-lingual airway soft tissue procedures listed, mandibular
and maxillary advancement is a reasonable treatment option for these patients,
either alone if there are demonstrable abnormalities of the facial skeleton or follow-
ing failure of the various soft tissue procedures. In patients with moderate or severe
sleep apnea, studies have demonstrated efficacy that is equivalent to that of CPAP
(23). Tongue reduction procedures (20,21) may also be considered in selected
patients. Surgical reduction of the tongue, however, generally requires a temporary
tracheostomy in the perioperative period, a possible deterrent for some patients. Morbidly obese patients may be candidates for bariatric surgery (24). Bariatric
surgery has also been shown to be beneficial for sleep apnea; however, due to the
long time required for weight loss, these patients should continue on their CPAP
machine until a follow-up sleep study demonstrates resolution of sleep apnea. If
these patients are not compliant with CPAP, then other airway enlarging procedures
may be contemplated in addition to the bariatric surgery. Tracheostomy is the historical gold standard treatment with an 100% success
rate and should be considered for patients intolerant to, noncompliant with, or
unsuccessful with CPAP (25,26).
