Continuous positive airway pressure (CPAP) may be the go-to treatment for sleep apnea, but many people struggle to use it every night. For those who cannot tolerate CPAP, new research finds that a combination of surgical techniques may bring relief.
The "multilevel" treatment includes removing the tonsils, repositioning the palate (roof of the mouth) and using radiofrequency to slightly reduce the size of the tongue. In combination, these procedures open up the airway and reduce breathing obstruction, the researchers said.
The study found that the multilevel surgery technique reduced the number of times people stopped breathing (apnea events) during sleep and improved daytime sleepiness. People also reported better quality of life after the treatment.
"Obstructive sleep apnea is common and many people cannot use the main treatments, like CPAP masks. Surgery is a valid option when an expert surgeon is involved, and it can improve outcomes," said the study's lead author, Dr. Stuart MacKay. He's an honorary clinical professor of otolaryngology, head and neck surgery at University of Wollongong, in Australia.
The researchers said that nearly 1 billion people worldwide suffer from sleep apnea. The airway becomes blocked during sleep, and as a result people stop breathing for short periods of time, multiple times throughout the night. People with sleep apnea have a higher risk of daytime sleepiness, motor vehicle crashes, and heart disease and stroke.
CPAP does a good job at keeping your airway open as you sleep, but the treatment — including a mask and a long tube — can be hard to get used to. The study authors said only about half of people with sleep apnea try CPAP.
For the new study, the researchers recruited 102 overweight or obese people with sleep apnea from six clinical centers in Australia, who were in their 40s, on average. The goal was to see if surgery could help adults with moderate or severe obstructive sleep apnea who weren't able to tolerate or adhere to CPAP devices.
Half of the volunteers were randomly assigned to receive the sleep apnea surgery, while the other 51 continued with medical treatment. Medical management consisted of encouraging weight loss, drinking less alcohol, changing sleep posture and medical treatment for nasal obstruction.
MacKay said the multilevel surgical technique is widely available in many parts of the world. For the patients in this study, surgeries were performed by seven experienced surgeons.
Six months after the surgical procedures, volunteers in the surgery group had about a 27% decrease in the number of apnea events at night. Those on medical treatment had just a 10% decrease.
People in the surgical group also had major improvements in levels of snoring and daytime sleepiness, as well as a boost to quality of life.
As with any surgical procedure, there are risks.
"The main risks of pain and bleeding are confined to the two weeks after surgery. Bleeding occurs in about one in every 25 patients. Long-term risks related to taste disturbance, feeling of sticking in the throat, swallow dysfunction are very rare, although they do occur transiently in some," MacKay said.
Dr. Steven Feinsilver is director of the Center for Sleep Medicine at Lenox Hill Hospital in New York City. He said, "Sleep apnea is a very common disease, about as common as diabetes, and similar to diabetes is associated with increased risk for cardiovascular events, such as stroke and heart disease."
He added that "CPAP works, but is a difficult treatment."
Feinsilver said that surgery that could provide a permanent cure has long been the goal for treatment.
"This study shows that relatively minor surgery, performed in a standardized fashion by skilled surgeons, can significantly improve sleep apnea compared to 'medical treatment' (essentially no treatment)," he said.
But he noted that even though people reported improvement, their nighttime breathing wasn't back in the normal range.
"This is certainly a major improvement, but it remains unclear whether outcomes (such as cardiovascular risk) will be significantly impacted," Feinsilver said. Also, he suggested that this multilevel surgery may only be an option for a select group of patients.
The report was published online Sept. 4 in the Journal of the American Medical Association.
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