Sleep Surgery in the Era of Precision Medicine

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Key points

  • Significant updates have been made to the original Stanford sleep surgery algorithm to reflect increased understanding of obstructive sleep apnea pathophysiology, patient phenotyping, and treatment outcome.

  • Overall treatment success of the patient is more important than individual surgical success.

  • The new algorithm focuses on precision in patient selection, procedural selection, and procedural accuracy.

  • Positive airway pressure therapy plays a significant role in the surgical algorithm.

  • Multilevel

How to approach a patient seeking surgery for obstructive sleep apnea?

A 52-year-old man with severe obstructive sleep apnea (OSA) and a history of septoplasty and uvulopalatopharyngoplasty (UPPP) seeks further care. Surgical options for him are not similar to those for a 22-year-old woman with mild OSA but presenting with equally debilitating daytime sleepiness and mood disturbance. What about a 64-year-old man with a history of nasal, palate, and maxillomandibular advancement (MMA) surgery 2 decades ago who now presents with moderate OSA? And what should be done

Why do we need an updated algorithm?

  • 1.

    Only one of the many OSA mechanisms is reliably addressed by surgical interventions : Airway critical closing pressure.

    Interventions provided, including CPAP, affect airway critical closing pressure. There are other important mechanisms, including respiratory arousal threshold, muscle tone, and loop gain, which cannot be addressed directly by surgery.1 Furthermore, loss of airway patency during sleep can be obstructive, mixed, or central in origin. Surgery mainly impacts obstructive apnea and

What is precise about the updated algorithm?

The updated algorithm adds precision in 3 areas.

  • 1.

    Precision in patient selection with greater understanding of OSA pathophysiology and the use of diagnostic tools, such as drug-induced sedation (sleep) endoscopy (DISE) (Fig. 1).

  • 2.

    Precision in introducing new procedures, such as UAS of the hypoglossal nerve or adult maxillary expansion (distraction osteogenesis maxillary expansion [DOME]), for previously unaddressed patient phenotypes (see Fig. 2).

  • 3.

    Precision in performing established procedures with

How to optimize PAP or oral appliance therapy?

To begin, even if a patient is referred for surgery, a careful history about positive airway pressure (PAP) therapy needs to be undertaken. This is after having conducted a careful medical history as well. Patients with significant medical comorbidities or predominant central apnea are better treated with PAP therapy. A thorough nasal evaluation becomes critical, because treating nasal obstruction has been shown to decrease PAP pressure or increase adherence to PAP.7, 8 Septoplasty, inferior

How to address the soft palate and tongue?

Although there are many different ways to perform tonsillectomy and palatopharyngoplasty, of greater importance is selecting patients who will do well with this procedure. This is well established by Friedman staging.17 Contemporary palate surgery tends to be tissue-sparing, where the desired result is achieved by repositioning of dilator muscles rather than their resection.18, 19, 20

Surgery related to the tongue can be grouped into (1) genioglossus-based procedures, (2) tongue base and/or

When is skeletal surgery considered?

One of the most discussed questions is, “When can phase 2 (MMA) be performed before phase 1 procedures?”

The most straightforward MMA candidate is one with dentofacial deformity. This does mean, however, that a class 2 patient with OSA would undergo double jaw rather than mandibular advancement surgery alone. Maxillary advancement is a more significant contributor to MMA success.26 This also means that a class 3 patient should not undergo the classic split-the-difference orthognathic planning,

What is the new definition of success?

3 patients scenarios reflect our response to this question:

  • 1.

    A patient with high BMI declines bariatric surgery and elects for MMA. Even though the postoperative apnea index (AI) is zero (starting from 54), the postoperative AHI was still in the 50s (all hypopnea). This is a surgical failure by Sher's definition. He was able to use CPAP after MMA, however, where he was unable to do so before. He has been adherent to CPAP, and a year later returned with normalized BMI and greatly improved daytime

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    Lateral pharyngeal wall tension after maxillomandibular advancement for obstructive sleep apnea is a marker for surgical success: observations from drug-induced sleep endoscopy

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    Keep the airway open and let the brain sleep

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  • A.E. Sher

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  • Cited by (20)

    • Anatomical determinants of upper airway collapsibility in obstructive sleep apnea: A systematic review and meta-analysis

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      Citation Excerpt :

      Today, treatment planning for obstructive sleep apnea (OSA) patients who fail nasal CPAP is based on symptom severity, polysomnography, patient history, physical examination, and endoscopic observations of the upper airway (UA) without quantifying UA collapsibility [1,2].

    • Automatic scoring of drug-induced sleep endoscopy for obstructive sleep apnea using deep learning

      2023, Sleep Medicine
      Citation Excerpt :

      In this current study, we collect a much larger number of videos and design a model capable of predicting obstruction degree at each of the four different sites (V, O, T, and E), which is evaluated against gold-standard annotations provided by surgeons. To simplify the problem, we leave out pattern of collapse, which can affect treatment strategy at the level of the velum and lateral pharyngeal wall [35–38]. The reasoning is to ensure that the model can distinguish between no collapse/collapse and the level of obstruction at each upper airway site before attempting to differentiate collapse patterns.

    • The correlation of maxillomandibular advancement and airway volume change in obstructive sleep apnea using cone beam computed tomography

      2021, International Journal of Oral and Maxillofacial Surgery
      Citation Excerpt :

      MMA is a surgical treatment for patients with moderate to severe OSA. According to the Stanford sleep surgery algorithm28, patients with a pre-existing dentofacial deformity, severe OSA, or complete concentric collapse of the velum and lateral pharyngeal wall collapse are indicated for MMA. The operation decreases airway resistance and obstruction2,3.

    • Does the Lack of Gender-Specific Apnea-Hypopnea Index Cutoff for Obstructive Sleep Apnea Impact Surgical Selection?

      2021, Journal of Oral and Maxillofacial Surgery
      Citation Excerpt :

      AHI, ESS, and FSS are not very well correlated, which suggests again that the severity of OSA based on AHI does not reflect symptoms. Patients are evaluated with the updated Stanford Sleep surgery algorithm that has been published in texts of otolaryngology, oral and maxillofacial surgery, and sleep medicine.19-21 In the updated algorithm, surgical decision-making is based on physiology, static and dynamic upper airway anatomy, and patient-specific preferences.

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    Disclosure Statement: None.

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