Sleep Apnea Surgery: Options for Adults and Children

Surgery can treat obstructive sleep apnea (OSA) by making the airway wider or keeping it from collapsing during sleep. In adults, it is usually considered when CPAP does not work for you or you cannot use it, and it often lowers sleep apnea rather than removing it completely. In children with large tonsils and adenoids, removing them is usually the first treatment.

Why surgery is not usually the first step for adults

CPAP keeps the airway open with gentle air pressure and works for most people who use it. It carries very little risk, so sleep doctors usually try it first. The American Academy of Sleep Medicine (AASM) 2021 guideline suggests starting with CPAP even when there is a clear airway problem, such as large tonsils or a small jaw.^[1]

The same guideline recommends that doctors talk about a referral to a sleep surgeon with adults who cannot tolerate or do not accept CPAP.^[1] If CPAP is the problem, there are also non-surgical choices, such as oral appliances and positional therapy. Our guide to CPAP alternatives covers those.

Nose, throat and tongue surgery

These surgeries are usually done by an ear, nose and throat (ENT) surgeon. Many people need more than one area treated, sometimes in stages.

• Nasal surgery — Septoplasty straightens a bent wall inside the nose, and turbinate reduction shrinks swollen tissue. It makes nose breathing easier and can make CPAP more comfortable, sometimes at a lower pressure. On its own, it rarely fixes sleep apnea.
• UPPP and other palate surgery — Uvulopalatopharyngoplasty (UPPP) removes extra tissue at the back of the throat, including part of the soft palate, the uvula and the tonsils if they are still there. Newer palate surgeries reshape the tissue instead of only removing it. These tend to help most when the soft palate is the main problem, and the benefit can fade over time.
• Tongue base surgery — If the back of the tongue falls back during sleep, a surgeon may shrink the tongue base or move tongue muscles forward. These are often done together with palate surgery.

Jaw surgery (maxillomandibular advancement)

Maxillomandibular advancement (MMA) moves the upper and lower jaws forward. This pulls the tongue and soft tissues forward and makes the whole airway bigger. It is done by an oral and maxillofacial surgeon.

MMA is often considered the most effective of the skeletal (bone) surgeries for sleep apnea, including some severe cases. It is also a bigger operation, with a longer recovery, braces before or after for many people, and possible changes in how the face looks and how the teeth meet.

Nerve stimulation, weight-loss surgery and tracheostomy

• Hypoglossal nerve stimulation (Inspire) — A small implanted device senses breathing and gently moves the tongue forward during sleep. It is for adults with moderate to severe OSA who cannot use CPAP and who meet set criteria. Read What is Inspire therapy? for the full guide.
• Bariatric (weight-loss) surgery — For adults with OSA, a BMI of 35 or higher and trouble with CPAP, the AASM guideline recommends talking about a referral to a bariatric surgeon.^[1] Losing weight can lower sleep apnea a lot, though some people still need treatment afterward. See weight loss and sleep apnea.
• Tracheostomy — A breathing opening is made in the neck, below the blocked part of the airway. It works, but it is rarely used today. It is a last resort for very severe cases when other treatments have failed.

Sleep apnea surgery in children

Children are different from adults. In many children, large tonsils and adenoids are the main cause of sleep apnea. The American Academy of Pediatrics (AAP) 2012 guideline recommends adenotonsillectomy (removing both tonsils and adenoids) as the first treatment for these children.^[2] Read more about tonsil removal in children.

Every child should be checked again after surgery. Children at higher risk, such as those with obesity or severe sleep apnea, and children who still snore or have symptoms, may need another sleep study. If sleep apnea remains, CPAP is often the next step.^[2]

Who is a candidate, and how surgery is planned

Surgery may be worth discussing if you:

• Cannot use CPAP — You have tried it, but it does not work for you or you cannot keep using it.
• Have a clear airway problem — Such as a blocked nose, large tonsils or a small or set-back jaw.
• Are healthy enough for surgery — Your heart, lung and other health problems affect the risks.
• Want a long-term option — And accept that you may still need some treatment after.

Before many airway surgeries, the surgeon may suggest drug-induced sleep endoscopy (DISE). Under light sedation, a thin camera shows where and how your airway closes during sleep-like breathing. This helps match the surgery to your airway. DISE is required before Inspire.

Recovery, results and follow-up

• Recovery — Nasal surgery and Inspire implants usually have the shortest recovery. Throat surgery such as UPPP often takes longer, with a sore throat and soft foods. Jaw surgery takes longer.
• Expectations — In adults, surgery often lowers sleep apnea rather than removing it. Some people still need CPAP or an oral appliance, often at an easier setting.
• Follow-up sleep study — Feeling better is good, but only a sleep study shows how well the surgery worked. It is usually done a few months after healing.

When to see a sleep specialist

See a sleep specialist if you or your child snores loudly, stops breathing or gasps during sleep, or is very sleepy during the day. Talk to one before any airway surgery, too. A sleep physician confirms the diagnosis, explains all your options and refers you to an ENT or oral and maxillofacial surgeon when surgery makes sense. After surgery, the sleep physician checks the results with a new sleep study.

Getting help in Cedar Park

Teddy Bear Pediatrics & Sleep Medicine does not perform surgery. Dr. Minal Patel is board-certified in both Pediatrics and Sleep Medicine. The practice offers in-lab and home sleep tests, CPAP and BiPAP care, Inspire evaluation and pediatric sleep medicine. Dr. Patel can refer you to a surgeon when you need one. The office is open Monday to Friday, 8:30 to 5:00, accepts new patients by appointment (no walk-ins) and accepts Medicaid and CHIP for sleep medicine patients.