Surgical Treatment of Moderate Sleep Apnea

Dear Community,
I have been a long time lurker on this forum and received so much great information I thought that I would give back and share results of my recent surgical treatment of my Apnea.

Background:
I am a 33yo male, healthy, non-smoking male, with moderate sleep apnea. I have been on CPAP (18 H20) since 2002 but struggled with compliance (e.g. using every night, removing mask in middle of the night). I had a severely deviated septum caused by trauma during contact sports and the tissue of my soft palate was overcrowding my airway. I was a heavy snorer. Never had surgery.

Treatment Decisions:
Treatment options considered included an “open approach” septoplasty with additional reconstruction of the nose, ESP/UPPP, and/or removal of the lingual tonsil (near the base of the tongue). I did loads of research on this site as well as reading original medical literature on the procedures. Considering my age, health, and individual anatomy (square jaw, no prior facial surgeries, etc), and a reasonably high-risk tolerance I chose two approaches.

1) Rhinoplasty including; septoplasty, reduction of left inferior turbinate, and reconstruction of cartilage in left nostril. And;
2) Expantion Sphincter Pharagyoplasty (ESP). This is essentially a less aggressive UPPP whereby they reposition the musculature of the soft palate to expand the airways. My uvula remained intact. Tonsils were removed.

I did not opt for the lingual tonsillectomy because neither the medical literature nor reported experiences demonstrated compelling success. I do note however that it is difficult to isolate the benefits of the lingual tonsillectomy because it is often applied as a buffet approach – combined with other concurrent procedures.

I have read horror stories on this site about ESP/UPPP and was concerned. Taking nothing away from the traumatic experiences some have endured with this procedure, I was comfortable with my decision given peer reviewed conclusions in the literature:

1) The average Apnea Index improved from 44.2 to 12.0 after expansion sphincter pharyngoplasty -- better than the standard UPPP procedure.
2) Selecting an arbitrary threshold of a 50% reduction in the Apnea Index, success was 82.6% in the expansion sphincter pharyngoplasty group compared with 68.1% in the UPPP group.
3) There were no postoperative complications noted in the 45 patients treated.
4) Side effects include severe pain and trouble swallowing lasting an average of 20.1 days.
5) I am an excellent candidate for this procedure because a) strong, square jaw b) small tonsils c) restrictions likely not due to tongue collapsing.

In short, the ESP procedure has promising results, is anatomically sound, and has minimal complications.

Moreover, I felt the negative reviews of this procedure received unfair attention in this forum. Internet forums in general are self-selecting pools of extreme opinions. Positive surgical results rarely get reported while negative experiences are highlighted. Highlighting a positive surgical experience is a secondary reason for my post.

Post-Operative Experience:
I am currently 10 Days post-op. The recovery has been tremendously painful as expected. The nose felt the worst immediately after but that pain was soon eclipsed by my throat followed by trouble swallowing beginning surgery+2. My prescribed medication was not strong enough so I did not drink fluids. I showed up to the post-op examination on surgery+5 and was almost readmitted due to de-hydration. At the same appointment, nasal splints and nasal sutures were removed. The sutures used in my throat are dissolvable. Switched to stronger pain medications, which aided in swallowing. As of surgery+10, I am rehydrated and in full recovery mode. I am still on a liquid diet and voice rest but I can run errands, clean house, and get minor work done. Anecdotally, I no longer snore.


Outlook:
It is too soon to tell what affect the surgery will have on my Apnea index and overall sleep health. I can tell that my nostrils are much clearer than before and my sleep has not suffered as a result of my currently swollen soft tissue. I anticipate my sleep will improve as the swelling goes down. I am optimistic that we have achieved a result as expected and the benefits of the ESP procedure will be permanent. I would advise that the both the Rhinoplasty and ESP procedures be considered where appropriate and, in mid-recovery mode, I have no regrets.

Of course I would be remis not to thank the superlative care and expertise of my doctors. I had this done at a research hospital with surgeons having direct and deep experience in the exact procedures performed. This are complicated issues. I woud strongly consider the capabilities of your surgeon before moving forward with any surgery.

I hope this write-up adds to the conversation and helps some of those considering surgical options for Sleep Apnea.

Good Luck.

Thanks for taking the time to write this up Tondi. I am going down the route of other treatment options now since PAP isn't working for me. I'll add this to the list of things to research.

I've actually wondered about UPPP since it seems to be so universally despised on message boards, but yet still done daily all over the US (apparently). I know the literature doesn't tout it as a cure for all, but you have to believe it is extremely helpful for some people.

I would think that the surgical approach to treating sleep apnea should be evolving, as there has been time to see which of the procedures touted 20 years has proven to be effective in the long term. I think those doctors who habitually ream every patient they see with identical all-inclusive procedures exactly like yesteryear would be the ones to fear. A progressive doctor is worth their weight in gold. I am not anti-surgery in all circumstances, just very conservative and cautious. In the interest of being open minded and informed, please do post any follow-up studies and more of your experience with your particular procedures. Best wishes.

where did you have the surgery done? i am debating to do similar surgeries, Please keep up posted on your recovery.

Alex

Hopefully, dedicated healers will eventually come up with the one thing we all hope for.
News about real success will spread at least as quickly as the news of failure has in the past.
Word of mouth tends to be more convincing than ads masquerading as news.

I wish you well and hope they do figure out a good surgical procedure some day.

I consider all the current crop of procedures to be experimental at best. I do NOT want to be a guinea pig who pays for someone to experiment on me. Especially until after we have long term results on a surgical procedure. I don't want to find out that it fails after x years, or that there are complications that pop up later in life.

Note, I do think correcting a deviated septum, tonsils, etc. are good if they are needed any way. If it also fixes your apnea, that's great.

[UPDATE]
I am happy to report, 6 weeks post surgery, I am fully recovered and have had no complications. Qualitatively speaking, my sleep has improved dramatically. I experience dreams every night, I no longer snore, and my alertness in the mornings is directly correlated to the amount of sleep I get. My nose is still healing from the aggressive reconstruction. My minor complaints have been excessive dryness of the nose and numbness on the tip of my nose. Both side effects are improving with time. However, noting these side effects is nit-picking given the dramatic benefits conferred with the pair of surgeries. I have my final seep study scheduled in a month so I will be able to quantify any benefits from that final study. I will report back with the results.

I feel like the early results have changed my life and I feel as though I have added years to my lifespan.

Just curious; is the doc planning on another PSG further down the road to rule out
re-development of symptoms as experienced by a few patients.
I'm not even sure if their procedures were the same as yours--but it's good to be careful.
Best wishes on your continued success.

Hi Tondi007 !

Please keep us updated on your progress !! please do !

Currently, i am out of all options besides MMA until i saw "Expansion Sphincter Pharyngoplasty", i am currently very interested in getting this procedure > MMA. Please, let us know what your results are, including will you be needing other procedures and what your new sleep test shows, if you will be getting one? your information can so many others who are also suffering from sleep apnea.


Thank You !

Hi, I think the opposition to surgery (especially UPPP) has been from people who've had it done (or knew others who did) and found that while they did well initially, their symptoms recurred within a year and in some cases were more difficult to resolve with Cpap than they had been originally because their new physical configuration did not lend itself to Cpap treatment as easily as it did to begin with. Of course I'm sure there are success stories and hopefully you'll do very well. Good luck!

hi julie !

I think there is something that people might have overlooked, while there are so many horrible stories on UPPP and stories of recurring symptoms. What separates "Expantion Sphincter Pharagyoplasty" from "UPPP", is that it's two complete different concepts. I see "Expantion Sphincter Pharagyoplasty" concept to the " MMA surgery", the idea is to expand the airway to creating more room, while holding the expansion in place. "MMA surgery" is through screws and metal plates and "Expantion Sphincter Pharagyoplasty" is through the attachment of muscles, retaining the space that is created from the surgery. While, "UPPP" in theory is same as the two other surgeries i just mentioned - Creating more room, but it does not address the single issue like the other two surgeries does. The UPPP does not guarantee to retain the space that was surgically created, from my best understanding the "Palate" cannot be 100% removed, so the remaining "palate" or any other soft tissues can still cause a blockage to the airway, especially over time.

I could be wrong about the the surgeries, so please do correct me if i am wrong.

Also, 60-80% of the OSA sufferers do not have Palatal Obstruction alone, they also have tongue based obstruction. So, single Palatal surgery is not enough.

Hi Tondi,
I'm about to go thru these same procedures and would really like to know how things are for you today? Also, which surgeon did you see?
Thanks for posting.
Mike

Anyone hearing of success of Expantion Sphincter Pharagyoplasty and deciding to undergo such a procedure is making a mistake. The choice among soft palate procedures must be based on the unique anatomy of an individual patient.

Hopefully any doctor performing this surgery will make a good evaluation before proceeding and not act solely on the patient's enthusiasm.

If anyone is considering surgery for OSA, the most important part of the above decision should be in the diagnostic procedures the surgeon uses to determine if 1) you are a candidate for surgery 2) if you are, where obstruction(s) are occurring 3) what surgical procedure(s) will address the concerns in #2. I think a large factor in surgeries not working has been the failure to do a complete assessment of OSA and using a single procedure to address all patients. Drug Induced Sleep Endoscopy (DISE) is a diagnostic procedure that I would simply insist on happening.

Did you read about that on Medgadget?