What This Guide Covers
Obstructive sleep apnea (OSA) is a condition in which the airway in your throat narrows or closes over and over while you sleep. Each pause can lower your oxygen level and briefly wake you. A physician diagnoses OSA with a sleep study, which can be done in a sleep lab or at home.[5]
The usual first treatment is positive airway pressure (PAP), most often a CPAP machine prescribed by a physician. Many people also try an oral appliance, a custom mouthpiece a dentist makes on a physician's prescription. When neither works, surgery may be an option.[1][3] If you have not tried them, see our guide to CPAP alternatives and our page on oral appliance therapy.
This guide maps the surgical options for adults with OSA and says which kind of surgeon usually performs each one. Two options have their own pages, so this guide only summarizes them: maxillomandibular advancement (jaw surgery) and hypoglossal nerve stimulation, which we compare with oral appliances in Inspire vs. oral appliance.
Who Performs Sleep Apnea Surgery
The word "surgeon" can mean several different specialists. The AASM guideline uses the term "sleep surgeon" for an ear, nose, and throat (ENT) surgeon, also called an otolaryngologist, or an oral and maxillofacial surgeon with training in upper airway surgery and an understanding of sleep medicine. It also recommends discussing referral to a bariatric (weight-loss) surgeon for some patients.[1]
Oral and maxillofacial surgery is one of the dental specialties recognized by the American Dental Association. These surgeons train in surgery of the jaws, face, and mouth, and some are board certified by the American Board of Oral and Maxillofacial Surgery (ABOMS). For sleep apnea, their main operations move bone: jaw advancement and genioglossus advancement. The American Association of Oral and Maxillofacial Surgeons (AAOMS) says these surgeons often work with sleep physicians, ENT surgeons, lung doctors (pulmonologists), and general dentists.[4]
ENT surgeons operate on the soft tissues of the nose and throat and also place hypoglossal nerve stimulation implants. Their national society, the American Academy of Otolaryngology-Head and Neck Surgery, supports nerve stimulation as a second-line treatment for moderate to severe OSA when PAP fails or cannot be used.[9] AAOMS lists UPPP, hyoid suspension, and nerve stimulators among the options its members may also provide.[4] Since training and experience vary, ask any surgeon which operations they perform and how often. Here is who does what:
- Jaw surgery (maxillomandibular advancement): oral and maxillofacial surgeons, sometimes working with an ENT surgeon.
- Genioglossus advancement: oral and maxillofacial surgeons.
- Soft palate surgery such as UPPP: ENT surgeons and some oral and maxillofacial surgeons.
- Tongue base procedures and tonsil removal: ENT surgeons.
- Nasal surgery: ENT surgeons.
- Hypoglossal nerve stimulation: ENT surgeons and some oral and maxillofacial surgeons.
- Weight-loss (bariatric) surgery: bariatric surgeons.
- Diagnosis and follow-up sleep testing: a physician, often a sleep medicine physician.
Who Is a Candidate for Surgery
In 2021, the AASM published a clinical practice guideline on when to refer adults with OSA for a surgical consultation. A consultation is a talk about options, not a promise of surgery. The guideline makes four recommendations.[1]
- If you cannot use or will not accept PAP and your BMI is under 40: your clinician should discuss a referral to a sleep surgeon as part of a talk about other treatment options. This is a strong recommendation.[1]
- If you cannot use or will not accept PAP and your BMI is 35 or higher: your clinician should discuss a referral to a bariatric surgeon. This is also a strong recommendation.[1]
- If you use PAP but have trouble with it because the pressure is too high: your clinician may discuss a sleep surgeon referral. Here, surgery aims to help PAP work better.[1]
- If you have a major structural problem in your airway, such as very large tonsils or a jaw shape problem: the guideline suggests trying PAP first before a surgical referral.[1]
What "cannot use PAP" can mean
Some people cannot sleep with the mask, take it off at night, or still have symptoms while using it. The AASM review found that surgery used as a rescue treatment in adults who could not accept PAP lowered sleepiness, snoring, blood pressure, and breathing pauses, and improved quality of life.[2]
Oral appliances are more often a good fit for mild and moderate OSA, so many people try one before surgery.[3] Our guide to oral appliances vs. CPAP explains the differences.
Other factors your team weighs
Your surgeon also weighs your overall health, weight, OSA severity, airway shape, and your own preferences. A small or set-back jaw may point toward jaw surgery. Collapse mainly behind the soft palate may point toward palate surgery. The AASM frames referral as a shared discussion between you and your clinician.[1]
In children, enlarged tonsils and adenoids are a common cause of OSA. See our page on sleep apnea in children.
The Evaluation Before Surgery
The AASM practice parameters state that the presence and severity of OSA must be confirmed before surgery.[3] That means a sleep study ordered and read by a physician. A dentist or surgeon may spot signs of sleep apnea and refer you, but the diagnosis comes from the physician.[5]
Exam and imaging
AAOMS notes that an oral and maxillofacial surgeon may do a head and neck exam, talk with your bed partner, and refer you for a sleep study if you have not had one.[4] If jaw surgery is possible, imaging of the jaws and airway is usually part of planning.
Drug-induced sleep endoscopy (DISE)
A sleep study shows how often you stop breathing, but not where the blockage happens. Drug-induced sleep endoscopy (DISE) helps answer that. Medicine puts you into a sleep-like state, and the surgeon passes a thin, lighted camera, usually through the nose, to watch the airway narrow. In one study of adults with OSA, an ENT surgeon performed DISE in an operating room, and 65 percent of patients had collapse at more than one level of the airway.[7]
DISE results can steer the choice of operation. For example, a Medicare local coverage policy for hypoglossal nerve stimulation requires a DISE that does not show a specific pattern of complete, ring-shaped (concentric) collapse at the soft palate.[10] Ask your surgeon whether you need it.
Surgical Options and Who Performs Each One
Some operations remove or tighten soft tissue. Some move bone forward. One uses an implanted device. Others bypass the throat or treat excess weight. Surgery can target one level of the airway or several, at once or in steps.[3]
Jaw surgery: maxillomandibular advancement (oral and maxillofacial surgeons)
Maxillomandibular advancement, or MMA, moves both the upper and lower jaws forward. The tongue and soft tissues attached to the jaws move forward too, which opens the airway.[4] It is major surgery done under general anesthesia by an oral and maxillofacial surgeon, sometimes working with an ENT surgeon.[4]
In a 2016 meta-analysis of 518 patients, 85.5 percent met the study definition of surgical success (breathing pauses cut by more than half and below 20 per hour). Only 38.5 percent reached the usual definition of cure, fewer than 5 pauses per hour. About three in four patients with data had already had another sleep apnea surgery.[8] For details on candidates, recovery, and risks, read our full page on maxillomandibular advancement.
Genioglossus advancement and hyoid suspension
The genioglossus is the main muscle of the tongue. It attaches to the inside of the chin. In genioglossus advancement, the surgeon moves a small piece of chin bone forward, which pulls the tongue muscle forward and tightens it.[4] Oral and maxillofacial surgeons perform this operation.[4]
Hyoid suspension moves the hyoid bone, a small U-shaped bone in the neck, and attaches it to the voice box cartilage or the lower jaw. This helps hold the base of the tongue steady.[4] Both operations are often done along with other procedures as part of a multilevel plan rather than alone.[3]
Soft palate surgery, including UPPP (ENT and some oral surgeons)
Uvulopalatopharyngoplasty, or UPPP, removes extra soft tissue at the back of the throat. This can include all or part of the uvula (the small flap that hangs at the back of the mouth), parts of the soft palate and throat walls, and the tonsils and adenoids if they are still there.[6] UPPP and related palate operations are performed by ENT surgeons and by some oral and maxillofacial surgeons.[4]
UPPP alone does not reliably bring breathing back to normal in moderate to severe OSA. For that reason, the AASM practice parameters say people with severe OSA should be offered PAP first, and people with moderate OSA should be offered PAP or an oral appliance first.[3] MedlinePlus notes that sleep apnea improves at first for about half of people who have UPPP, but the benefit wears off for many over time.[6]
Tongue base procedures (ENT surgeons)
The base of the tongue can fall back during sleep and block the airway. Tongue base procedures shrink or remove some of that tissue. One method, radiofrequency ablation, uses heat energy to shrink tissue. The AASM practice parameters say it can be considered for mild to moderate OSA when PAP and an oral appliance are not options.[3] Other tongue base procedures remove part of the tongue base. They are performed by ENT surgeons and are usually part of a multilevel plan.[3]
Nasal surgery (ENT surgeons)
A blocked nose can make CPAP harder to use. Nasal surgery can straighten the wall between the nostrils (septoplasty) or shrink swollen tissue inside the nose (turbinate reduction). These operations are performed by ENT surgeons.
In a 2015 meta-analysis of people with OSA and nasal blockage, nasal surgery alone lowered the CPAP pressure they needed. In a smaller group, nightly CPAP use rose from about 3 hours to about 5.5 hours in the short term.[12]
Hypoglossal nerve stimulation (ENT and some oral surgeons)
The hypoglossal nerve controls the tongue. Hypoglossal nerve stimulation uses a small, pacemaker-like implanted device that stimulates the throat muscles through this nerve so the airway stays open during sleep.[5] Inspire is one brand. The implant is placed by ENT surgeons and by some oral and maxillofacial surgeons.[4] The ENT surgeons' national society calls it a safe and effective second-line treatment for moderate to severe OSA in people who cannot use or do not benefit from PAP.[9]
Candidates must meet specific criteria. A Medicare local coverage policy, for example, requires an age of 22 or older, a BMI under 35, a breathing-pause count of 15 to 65 per hour, documented CPAP failure or intolerance, and a DISE result that fits the device.[10] For a side-by-side comparison, see Inspire vs. oral appliance.
Tracheostomy (last resort)
A tracheostomy creates an opening in the front of the neck into the windpipe, so air bypasses the part of the throat that collapses. It works, but it is a major life change. The AASM practice parameters say it should be considered only when other options do not exist, have failed, are refused, or when it is urgently needed.[3]
A 2014 meta-analysis of 18 studies, mostly case series, found that the apnea count fell from about 73 to near zero per hour after tracheostomy. Some patients developed a different kind of breathing pause (central apnea) at first, which improved over the following months.[11]
Weight-loss (bariatric) surgery referral
For adults with OSA and a BMI of 35 or more who cannot use PAP, the AASM recommends discussing a referral to a bariatric surgeon.[1] The AASM review found that bariatric surgery lowered breathing pauses, blood pressure, sleepiness, snoring, and BMI in adults with OSA and obesity. It also noted a risk of low iron absorption that can usually be managed with iron supplements.[2] Bariatric surgery is done by bariatric surgeons, not dental surgeons.
Risks and Recovery
Every operation carries the general risks of anesthesia and surgery, such as bleeding, infection, and reactions to medicine.[6] MedlinePlus also notes that surgery may not completely cure OSA and may have long-term side effects.[5] Very limited evidence in the AASM review did not show a clinically significant rise in serious, lasting side effects from upper airway surgery.[2] Ask your surgeon about your own risks.
- Soft palate surgery: a very sore throat for up to several weeks, speech changes, mucus in the throat, dehydration, and sometimes liquids coming up through the nose when you drink. That last problem is most often temporary.[6]
- Jaw surgery: swelling, a period of diet limits, numbness of the lips or chin, and changes in bite or facial profile. See our MMA page for details.
- Nerve stimulation: the risks of an implant operation plus device-related issues. Our Inspire comparison covers these.
What recovery generally looks like
Recovery depends on the operation. UPPP, for example, most often requires an overnight hospital stay, soft foods and liquids for about two weeks, and two to three weeks for a full recovery.[6] Jaw surgery usually involves a longer recovery. Nerve stimulation and nasal surgery are generally smaller operations than jaw surgery. Ask your surgeon for a written recovery plan.
Follow-up sleep testing
Feeling better is not proof that surgery worked. The AASM practice parameters say that after healing, patients should have a follow-up test of breathing and oxygen during sleep, and should be followed over time in case OSA comes back.[3] Some people still need CPAP or an oral appliance after surgery.
Cost and Insurance
There is no single price for sleep apnea surgery. The total depends on the operation, surgeon, anesthesia, facility, imaging, DISE, any device, your region, and how complex your case is. Ask each office for a written estimate that lists every part.
Because OSA is a medical condition, surgery is usually billed to medical insurance, not dental insurance. Plans often require a sleep study diagnosis, proof that PAP was tried, and prior approval. A Medicare local coverage policy for nerve stimulation is one public example of how detailed these rules can be.[10] For palate surgery, MedlinePlus notes that a plan may not pay if you have snoring without OSA.[6]
Before you schedule, ask your plan for its written criteria, and ask the surgeon's office whether it handles prior approval. If an oral appliance is part of your plan, our guide to oral appliance cost and insurance explains how that coverage works.
Next Steps and Finding a Provider
Start with your physician. Obstructive sleep apnea is diagnosed by a physician through a sleep study, done in a lab or at home. If you have a diagnosis and CPAP has not worked for you, ask your physician about an oral appliance trial and about a referral for a surgical consultation. Your physician can also refer you to an ENT surgeon or a bariatric surgeon if those options fit.
To look for an oral and maxillofacial surgeon near you to discuss jaw surgery or genioglossus advancement, use our provider directory. If you want to try an oral appliance first, browse our list of dentists who provide oral appliance therapy, grouped by state. A dentist fits an appliance on a physician's prescription. Ask any provider about their training and how they work with your sleep physician.
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