Surgical treatment of obstructive sleep apnea

AORN Journal, Sept, 2005 by Wayne Colin, Susan Duval

Often patients begin treatment with turbinate reduction, tonsillectomy, palatoplasty, and genioglossus advancement. Using a combination of genioglossus advancement and hyoid suspension should be weighed very carefully because of the potential for tongue edema and dysphagia, especially in the older adults. (51) Maxillomandibular advancement is reserved for use when less invasive procedures have been inadequate. For patients with clear evidence of retrognathia (ie, either or both jaws recede with respect to the frontal plane of the forehead), however, maxillomandibular advancement is a more definitive option for resolving OSA. (52) When disease intensity and obesity are severe, it is likely that staged procedures will be necessary in an attempt to resolve the OSA. (53)

TREATMENT OF THE TONGUE. Perhaps the greatest current controversy with surgical management of OSA is whether to routinely treat the tongue base at the time of initial intervention. A variety of observations argue in favor of combined palatal and tongue treatment rather than palate-only therapy.

In one study, the cure rate for patients with tonsil and palatal anatomy stratified in a staging system according to size (ie, small tonsils with long palate) was less than a 10% after tonsillectomy and UPPP. (54) In contrast, patients who had very large tonsils and a short palate experienced an 80% success rate with intervention. Diminutive tonsils and elongated palate was the most common anatomical presentation, not the exception, implying that the poor cure rates were from obstruction at another site, such as the tongue base, or from inadequate palatal surgery. A meta-analysis of 500 UPPP procedures revealed that, at best, one-third were treated successfully by UPPP; (55) whereas, stage I procedures (ie, combined palatal and tongue-base surgery) demonstrate a 60% or greater success rate? (56) For mild to moderate OSA without morbid obesity, a jaw-advancement appliance to protrude the jaw and tongue can be effective at resolving OSA without specific palatal therapy. (24)

POSTOPERATIVE CONSIDERATIONS

Emergence from anesthesia can present a challenge to keeping a patent airway. Many anesthesia care providers prefer to cautiously remove the endotracheal tube while the patient is deeply anesthetized and ventilating spontaneously but only if the patient has an easy airway and is only moderately obese. The surgeon routinely places an oral or nasal airway after diligent airway suctioning. He or she removes the airway after the patient wakes, usually in the postanesthesia care unit (PACU). Deep extubation is preferred to prevent the patient from coughing, bucking, and producing bloody secretions that are more notable during awake extubation.

Careful physical monitoring of the patient is necessary throughout this procedure. The anesthesia care provider monitors the patient's pulse oximetry, electrocardiogram, and blood pressure, and observes the patient until the patient is fully awake. The nurse should be especially observant for postoperative edema. Antihypertensive medications are used to maintain a blood pressure less than 140 mm Hg systolic and 90 mm Hg diastolic. Vigilance to rapid control of blood pressure is important particularly when bone-based procedures have been performed because the narrow space will ooze in proportion to the degree of hypertension, and oozing in the airway could precipitate an airway obstruction in a semiconscious patient. The surgeon, anesthesia care provider, and circulating nurse place the patient in a semisitting position to ensure an adequate airway.