Therapy is the first course of action recommended by doctors to treat moderate to severe sleep apnea. However, if a mouthpiece won’t work, getting patients to follow through with CPAP therapy by using apnea machines remains an issue due to various reasons, such as difficulty in wearing the mask, problems getting used to having air pushed into their nasal passage, or the noises the machine makes. Surgery, while not an easy option, is still a feasible choice for some. It is not a decision to undertake lightly, and considering surgery to stop snoring should not be a blanket resolution for all patients. Success rates for apnea surgery varies. The National Center for Biotechnology Information puts forth the success rates of the various sleep apnea surgeries. It must be noted that a successful surgery is contingent on other factors, including the overall health of the patient, their treatment follow through, and lifestyle.
Types of Surgery
There are numerous surgical operations available. The most common methods are nasal surgery, UPPP, soft palate implants, hyoid advancement, tongue advancement, tongue base reduction, lower jaw advancement, and tracheostomy.
Nasal obstruction is caused by a variety of problems such as a deviated septum or adenoids. Mild obstructions that cause allergies can be treated with medication. More serious obstructions result in having trouble breathing and sleep apnea. The areas of the nose concerning procedures are the septum (separates the left and right airways in the nose – our nostrils), turbinates (structures inside the nasal wall that warm and humidify the air we breathe) and the nasal valve, whose primary function is to limit airflow. Turbinates can become enlarged, reducing them facilitates better airflow. Turbinate reduction surgery is typically an outpatient procedure, and includes straightening the septum. Nasal valve surgery rectifies their collapse due to weaknesses in lower nasal cartilages – these hold the nostrils open. This surgery also encompases the septum, removing the deviated cartilage and is placed to strengthen the valve.
UPPP, or UP3, is the abbreviation for uvulopalatopharyngoplasty, or palate/ uvula removal surgery. It is the most common of the apnea surgeries. The procedure is a combination of removal of the excess tissue in the soft palate and pharynx, and tonsils (tonsillectomy) if they are present.
Sutures are then placed in the upper airway to keep the area open and prevent collapse, and to keep normal functions such as breathing, speaking, and swallowing unaffected. The upper airway is the most common place of obstruction in apnea sufferers. UPP is not an outpatient surgery, and patients can remain in the hospital for up to a week. Marked improvement is noted in snorers after undergoing this procedure.
Soft Palate Implants
Otherwise known as the Pillar Procedure, this surgery involves placing tiny implants into the soft palate to treat mild cases of sleep apnea. The purpose of the implants is to stiffen the soft palate in response to inflammation. A stiffer palate has a smaller chance of making contact with the back of the pharynx when the muscles relax during deep sleep, which in turn lessens tissue vibration, thus resulting in a reduction of snoring and apnea events. This procedure is minimally invasive and can be done while the patient is awake after they are administered local anesthesia. The Soft Palate surgery is not recommended for people with severe apnea, or those who are overweight.
The hyoid is a u-shaped bone in the neck. Its primary function is to support the tongue in movement and swallowing. Sufferers of sleep apnea typically have a large tongue base. When in a deep sleep and the muscles are relaxed, the base of the tongue falls backwards and make contact with the pharynx obstructing the throat and air passages. Surgery of the hyoid is minimally invasive and should take no more than an hour to complete. The procedure repositions the hyoid by moving in forward along with its muscle attachments. This expands airways and prevents their collapse. The surgery can be performed in conjunction with UPP, which targets airways as well.
The medical term for tongue advancement surgery is genioglossus or genial tubercle advancement, where the base of the tongue is pulled forward with the muscle attached to increase the size of the airway. The procedure can be performed with UPP or the jaw surgery MMA (Maxillomandibular). While similar to hyoid advancement surgery, tongue advancement is more invasive. A less invasive version of the surgery is available, where the tongue is still drawn forward however rather than being secured with a titanium plate the tongue is secured with a plastic cord and titanium screw attached to the lower jaw bone.
Tongue Base Reducement
Aside from advancing the tongue, there is reducing its size of the tissue in its base. There are a coupe methods to achieve this. One is applying radiofrequency waves to a redirected site where a pulsating energy surge shrinks the tissue. This is a minimally invasive procedure, however more than one treatment is necessary to achieve the desired results. A second method to reduce the base is by excising it either by electrocautery (conducting heat at high temperatures via an electric current) or coblation (using radiofrequency without heat). An excision procedure requires an overnight hospital stay.
Lower Jaw Advancement
The procedure known as MMA for the lower jaw is more invasive, challenging, and intricate than the others discussed, as it involves a long recovery process after cutting bone and the repositioning of teeth,enlarging both the palate and tongue regions. A side effect of the surgery includes having patients getting their jaws wired shut for weeks during the healing process. Additionally, staying at the hospital for several nights for observation is required. Due to the risks this procedures poses, few doctors will perform it frequently.
This surgery creates a hole in the neck via the trachea (windpipe) in order to create a passage to get air directly into the lungs from the neck. A tracheostomy is a long term treatment of apnea for the morbidly obese or patients who have tried and failed other forms of therapy or surgery. In some cases, a tracheostomy can be healed shut and surgically closed when it is not needed anymore, in others it is permanent. For this reason, the decision to go through with this surgery is reserved for those who are very ill, and considered a “last resort”, or in an emergency situation when there is no other choice.
Paying for Sleep Apnea Surgery
If you have exhausted all possible non surgical options, your physician may recommend surgery to alleviate your sleep apnea. Most insurance companies cover the sleep studies needed to receive an apnea diagnosis, along with CPAP machines. Under the Affordable Care Act, sleep apnea is considered a pre-existing condition and therefore no individual can be denied coverage for treatment. Medicare Parts A and B cover different things regarding sleep disorders; Part A will cover the care a hospital or skilled nursing facility provides, and Part B
May cover physicians, outpatient services, and supplies for treatment.
In order for an insurance company to cover apnea surgery, they will need documented proof of a diagnosis, and a record of therapy that has been attempted. Since there are so many different options for apnea surgery, insurance companies may not cover all or part of them. This decision can be appealed depending on your insurance provider. It is best to research your provider to find out what they cover, as each one is different. An out of pocket copay will probably be required by any specialist you visit.
The average costs of sleep apnea surgery can range anywhere from $3500 to $10,000.
The Healthcare Cost and Utilization Project put forth by the US Department of Health and Human Services reports that the UPP procedure can cost at a minimum of $6400. The average for nasal or palate surgery can cost over $10,000. Additionally, your specific location, hospital, and surgeon can affect the price. In the event you do not have insurance, financial assistance may be available to help cover the costs of surgery. Hospitals often offer payment plans to as an alternative to paying in one lump sum.
In summation, it is important to consider all the risks and potential complications that come with any surgery and the recovery time afterwards. Communicate and work with your physician about other possible treatments prior to deciding to go through with surgery. If surgery is the only option left, discuss with the doctor which one would best suit your condition.