Response Provided by Dr. Kasey Li
April 20, 2011
I will do my best to be as thorough as possible in answering your question. This is actually going to open up a can of worms...and I will be one of the very few surgeons with this view. I am not going to win any fans, but it is what it is as it is my honest opinion.
The central issue with sleep apnea surgery is that very few surgeons actually have some clues in what they are doing. The data on surgery is murky at best. What I can tell you is that there are only 3 operations that I feel comfortable as reasonable options where a majority of patients (properly selected) will improve without significant side effects.
1. Nasal surgery to improve nasal breathing and possibly improve CPAP tolerance if nasal congestion is a major problem.
2. Pharyngoplasty WITH tonsillectomy to improve sleep apnea WHEN the tonsils are VERY LARGE.
3. Maxillomandibular advancement.
Years ago, I did over a hundred genioglossus advancements with pharyngoplasty per year because I followed the phase protocol. As the number of cases piled up, I started to have more and more concern about the efficacy of the procedures. I found that only a few patients had dramatic improvement from these operations (I do get home runs from time to time, but just not nearly as many as I'd like). Many patients continued go on to the phase protocol by having MMA. However, many patients simply dropped out because they were discouraged by the results. I started to really wonder about the efficacy of genioglossus advancement. To me, there is little to no data documenting the effectiveness of this operation. I then reviewed the results of other very experienced surgeons and guess what, similar to mine. Additionally, although there are many, many published papers on the effectiveness of genioglossus advancement, they are all combined with other procedures, such as UPPP, nasal surgery...etc. So which procedure helped? I also saw 5 or 6 patients that underwent an isolated genioglossus advancement performed by an experienced surgeon. However, none of them had any appreciable improvement. A couple of patients' sleep apnea got worse after the operation. Therefore, I am always hesitant in offering genioglossus advacement. The same goes for hyoid advancement.
One may then ask, why do all those surgeons report the success of genioglossus advancement/hyoid advancement. If you examine those data, they are all combined with UPPP/nasal surgery, you will see that typically, the reported response rate is 40-60% and improvement is about 40-50% in reduction in RDI. The results are OK, but rarely a game changer. Additionally, the standard deviations are all very large, which means that some patients did not improve at all and some got worse. Making someone worse is a real concern and should be for all surgeons. By the way, sleep endoscopy DOES NOT improve the ability for surgeons to select out patients who would be favorable responders, so why do it?
I do my best to offer reasonable options for patients. If someone has very unfavorable upper airway anatomy, moderate/severe sleep apnea, no or small tonsils and no redundency in the soft palate, I would tell them that the only good option for them is the MMA. Otherwise, don't do any surgery. I know I scare off a lot of patients and they go elsewhere so they can have something less invasive, but they ended up having MMA at the end. It happens not infrequently, just look at the blogs. When UPPP with genioglossus or nasal surgery success rate is so low, why do it? Consider the risks and expenses.
MMA is often a game changer for patients, but not always. When a patient does not have a dramatic improvement from MMA, I get concerned in offering additional surgery. I like predictable, successful results. I don't like to just do surgery and see what happens. However, many patients are desperate in getting better sleep, and I understand. I am willing to work together and will try my best in doing additional surgery, as long as my patients understand that these additional surgery will be a lot less predictable and there may be no improvement.
Finally, I am very selective when it comes to MME. I only offer it to patients with very narrowed jaws. The results have been pretty good. Not as good as MMA but better than UPPP/genioglossus advancement. In general, the narrower the jaws, the better the improvement.
I am sure I will get more questions. I am happy to answer them.
Kasey Li, MD, DDS