Surgical Treatment of the Sleep Apnea Syndrome in the Twenty-First Century

Sleep apnea syndrome is a disease of high prevalence and high morbidity, for which surgery used to be the only possible therapeutic approach. Uvulo-palatopharyngoplasty (UPPP) was the technique used until the nineteen eighties. However, surgery has largely been abandoned since the introduction of nasal continuous positive airway pressure (CPAP), which has become the main treatment option today. Surgery remains an alternative for patients who do not tolerate nasal CPAP. Since the range of surgical techniques available is wide, patients must be carefully evaluated with fiberoptic nasopharyngoscopy and lateral cephalometric radiograph to determine the level of the obstruction. In almost 98% of sleep apnea patients the soft tissue structures of the upper airway and the underlying maxillo-mandibular skeleton are disproportionate. Therefore, the choice of surgical procedure depends on the site of obstruction (nose, retropalatal or retrolingual region, or a combination). Here we review the various surgical procedures available and their efficacy when performed alone or in combination. These procedures are: classical uvulopalatopharyngoplasty and its modifications, genioglossus advancement techniques combined with UPPP, and retropalatal and maxillo-mandibular advancement, a highly aggressive technique which treats retropalatal and retrolingual regions simultaneously and is effective in 95% of cases, but has a high morbidity. We also discuss nasal surgical procedures (though they are unlikely to solve the problem), radiofrequency, and palatal implants. We assess the efficacy of these methods, bearing in mind; a) the differences in the criteria used for defining surgical success and b) the fact that they are often applied simultaneously or sequentially.