For adults with obstructive sleep apnea, the standard treatment is positive airway pressure therapy (such as CPAP, BPAP, or APAP).  Surgery is reserved for patients who are unable to tolerate or benefit from positive airway pressure therapy.  For children, adenoidectomy and/or tonsillectomy for sleep apnea is the standard treatment.  Positive airway pressure therapy is not an ideal treatment for most children.  This is due to concerns over effects on facial growth and difficulty that children may have with tolerating it through the night.  It is reassuring that surgical outcomes in children–while by no means perfect–are relatively good, especially when the tonsils or adenoids are enlarged and when the child is not considered substantially overweight.

What about tonsillectomy for sleep apnea as first-line treatment in adults?

Just like in children, adults with enlarged tonsils also do better after sleep apnea surgery that includes tonsillectomy.  One reason seems to be that the physical removal of the enlarged tonsils immediately opens up space for breathing and improves the sleep apnea.  Many have wondered whether adults with sleep apnea and markedly enlarged tonsils should be treated with surgery that includes tonsillectomy.

The December 2016 issue of the medical journal The Laryngoscope included an interesting study examining this question.  Twenty-nine adults with markedly enlarged tonsils (size 3+ or 4+ on the Friedman scale), obstructive sleep apnea, and no substantial obesity (body mass index below 32 kg/meters squared) underwent tonsillectomy alone.  One patient was lost to follow up, but the rest of the patients had sleep studies before and then 6 months after surgery.  Impressively, the average apnea-hypopnea index decreased from 40 to 7 events per hour after undergoing tonsillectomy for sleep apnea, with only 2 patients having anything worse than mild sleep apnea.  There were also substantial improvement in the score on the Epworth Sleepiness Scale score that measures daytime sleepiness (mean score decreased from 11 to 6).

tonsillectomy for sleep apnea

View of the mouth, showing the tonsils

Are there other studies of tonsillectomy for sleep apnea?

This study followed previous smaller studies showing substantial improvement or resolution in sleep apnea after tonsillectomy alone and that tonsil size and body mass index were associated with outcomes after tonsillectomy alone and that tonsillectomy could reduce the required CPAP pressure in those who did not have resolution of their sleep apnea.  This was supported by a larger study of 202 adults published in 2015.  This study showed a 95% chance of surgical success after tonsillectomy for sleep apnea, with a decrease in the average apnea-hypopnea index from 18 to 3 events per hour.

So why isn’t tonsillectomy for sleep apnea a first-line treatment in adults?

There are likely many reasons.  First, not all patients have tonsils that are markedly enlarged.  I would estimate that this about 5-10% of all adults with sleep apnea would be ideal candidates for tonsillectomy as a first-line treatment.  This figure seems relatively small, but it still is quite a few patients who could have their tonsils removed because sleep apnea is so common.  Second, most of these studies are relatively small.  It would be important to repeat the studies in larger groups, just to confirm the findings.  Third, the studies are not what are called randomized trials.  Randomized trials could include patients with sleep apnea and markedly enlarged tonsils, either performing tonsillectomy or observing them without treatment for a period of time (6 months, for example).  Unfortunately, it turns out that making people wait for surgery just to be part of a research study is incredibly difficult.  Patients will prefer not to be involved in these studies if they are interested in having surgery (or any treatment).  Finally, there are perceptions about surgery for sleep apnea that we have to overcome.  I have written before that most surgeons, other physicians, and the public think that there is only one surgery for sleep apnea.  That is just not the case.

What would I recommend?

We are in the midst of a major change in rethinking sleep apnea surgery–for all parties involved.  The goal is developing a tailored approach to sleep apnea treatment with an approach that is often called personalized medicine.  I see many young adults with markedly enlarged tonsils who are struggling with positive airway pressure therapy, including many with mild sleep apnea who are not overweight.  For these patients, I think it is very reasonable to think about surgery as a first-line option instead of being on positive airway pressure for the rest of their life.  These patients have a greater than 90% chance of clearing up their sleep apnea with tonsillectomy alone.  Not every one of them will want to have surgery, but this should be part of the discussion because the results will be so good, based on everything we know about sleep apnea surgery outcomes.

As a sleep surgeon, I see many patients who want surgery because they simply do not like positive airway pressure therapy, even though they are doing well with it.  In fact, I actually discourage many of these patients from surgery.  My approach is always the same: if you are doing well with positive airway pressure therapy, keep using it.  The one caveat are those patients who have a very high chance of resolution of their sleep apnea with a straightforward procedure like tonsillectomy.

 

 

20 Responses to “Tonsillectomy for Sleep Apnea as First-Line Treatment in Adults”

  1. Joseph Tidwell

    If a study was to come up for volunteers for a tonsillectomy i’d do it in a heartbeat.. I”m stuck on a cpap at 18 for my pressure. I have issues with mask leaks and my quality of sleep is frequently hampered by it.. I’ve used aloe vera to help seal the mask which helps alotta times, but i’m glued to this machine when I sleep.. I cannot even go backpacking over night any more… So, yes if theres a study needing volunteers, sign me up!

    Reply
    • Dr. Kezirian

      Unfortunately, most research studies do not cover costs of surgery. If you have markedly enlarged tonsils, there is a reasonable chance that removing those tonsils can clear up your sleep apnea. Since you are struggling with CPAP, you may want to see a sleep surgeon for an evaluation.

      Reply
    • Mark

      Hi Joseph

      I can’t help you with an extensive sleep study. But I can let you know how my personal experience goes in the next couple of weeks.

      I have been in sleep clinic for two overnight stays, first was to determine severity and second was for titration for the APAP machine. I have had corrective surgery for septum, sinuses cleaned and had turbanites shaved to make room. 6 months later I am now having the tonsillectomy – my tonsils are massive, enlarged is putting it mildly.

      I hate the machine, 6 months later using it and I’m still reliant on sleeping pills to put me under – quality of sleep is terrific while asleep but like you; dependency and mask leaks are incredibly annoying. Also pretty sure I’m getting face wrinkles prematurely (not the main concern but definitely additive).

      Next week Friday 23rd Feb 2018 – the buggers are coming out! I will let you know if I noticed a remarkable improvement and if it’s potentially worth it – especially if you can have a checkup to see if you do indeed have enlarged tonsils.

      Worst case scenario, I am hoping if the tonsillectomy doesn’t cure my sleep apnea, it at least provides enough room for improvement for me to move away from the machine and use one of those MAD (mandibular advancement devices). The proper ones you get made by a dental surgeon! Not your pharmacy variety.

      But fingers crossed that surgery cures it first!

      Reply
  2. Jules

    Yes-please let us know. My husband has huge tonsils. We r thinking of getting them removed or shaved down.

    Reply
    • Ruth H

      Hi Mark – I would love to know how it is going also. I’m scheduled to have surgery in early June. Was told I have severe apnea so I’m hoping this helps. I heard it is painful the first few days, but well worth it. Would love to hear your story.

      Reply
  3. Joe

    I would like to know your outcome too. I cannot fall asleep with the CPAP, so it is no help to me. A friend said the tonsillectomy was a miracle for her daughter. How has it been for you?

    Reply
    • Melwyn

      Hi Joe, how old was your friend’s daughter? If she’s a child, then the success rate is very high.

      Reply
  4. Lauren

    Waiting to hear on this too. My husband can’t get very much sleep with the mask and is having many correlated health problems. We are at hospital now being told tonsils are inflamed/ enlarged. He literally hasn’t slept a wink in 3 days and is catatonic. Wonder if they would do tonsillectomy on an emergency basis.

    Reply
  5. Kathe

    Im waiting to see how Mark is doing as well. I have the dental appliance after years of frustration with the CPAP I now suffer from claustrophobia or more a fear of suffocating from the machine leaking, and causing what I can only describe as vapor lock seaming to pop my ears if my mouth opened at all, so no more chin strap, no more cpap, Im a month into the MAD dental appliance and turning it every 4 days to see if adjusting it (until I resemble a pug dog) will help. I have insomnia now too unless I take all my nightime meds.

    Mark hope all went well.

    Reply
    • Dr. Kezirian

      It would be great to hear how Mark is doing, but the nice thing about these studies is that they include scientific evaluation of groups of patients. I hope you have a great result with your MAD. Surgery like tonsillectomy can have substantial pain during the recovery period, but the good thing about surgery is that there is nothing to wear or tolerate like there is with CPAP or a MAD. This makes it easier for patients with insomnia to experience resolution of their sleep apnea after surgery if they are really good surgical candidates like patients with markedly enlarged tonsils. Studies show that women, especially, with sleep apnea will often seek medical care for insomnia that turns out to be mainly related to sleep apnea. However, people with insomnia and sleep apnea should not expect that their insomnia will clear up with treatment of their sleep apnea alone.

      Reply
  6. ricky woodruff

    Hi.. my name is rick and i had a sleep apnoae test.. i stopped breathing 55 times a hour. My lack of sleep is making my life intolerable.. i fall asleep on couch when i lay down after work andcwithin a minute or 2 wake up and are gasping for air.. at times i am afraid to go too sleep fearing i will have a stroke or something.. this has gone on for many years and i cant remember the last time i had a good sleep.. i feel totally weary in the mornings but late at nights feel wide awake so it makes it harder to go to sleep..i did not want a machine as i know of others who have had them who cant stand to use them and gives them a feeling if intrusion with there partners.. i am due over the next 2 months to have my tonsils removed and cartlidge in the middle of my nose straightened.. i am hoping for success and i know it will be pain but hoping fir plenty of gain. I am 56 years old and my tonsils are very big.. i would like to let you know my experience from start to finish over the next 4 mknths or so and will give you the thumbs up or down as to how it works for me..thank you

    Reply
    • Dr. Kezirian

      Thank you, but this is not a good place to document your entire experience. Please do feel free to share with others, whether on Facebook or some other platform. It will be much easier for others to follow everything about your surgery and recovery there.

      Reply
  7. Craig Smiles

    Hi all, I had my tonsils out on the 10th of July, although not because of the severe sleep apnea I suffer from but for persistent infection. However I have and so has my wife noticed a massive difference regarding sleeping and its only been 12 days. As soon as everything is healed properly i’ll be going back to my doctor to get retested and hopefully get rid of my cpap machine.

    Reply
    • Dr. Kezirian

      Craig, thank you for sharing your experience. I am so glad to hear that you have done well.

      Reply
  8. C P

    Going in tomorrow for tonsil removal tomorrow. Sleep ENT wanted to do a UPPP but insurance denied it because no blockage was documented. Need an endoscopy to determine blockage… seems a bit counterintuitive.
    I have moderate apnea and often wake with a headache.
    I am very hopeful that I’ll be able to sleep and have a bit more energy.

    Reply
  9. Mathew

    Hey im 18, not overweight, exercise everyday, and i have mild sleep apnea.
    My tonsils are enlarged and i do have a adneotonsillectomy next week. Do you think it will work?

    Reply
    • Dr. Kezirian

      If they are markedly enlarged, that is certainly going to make it more likely that you would get a successful result. However, it is not possible for me to make blanket statements or give medical advice without examining you myself.

      Reply
  10. Elsie

    I am 20 years old, I have had sleep apnea due to enlarged tonsils for over a year now. I have extreme anxiety and have been postponing the surgery and have finally decided to get it done next month. I am worried sick because I am scared that this is going to kill me while i’m aleeoing and that i should go in for emergency surgery. I snore excessively and wake up by myself sometimes due to not being able to breathe. I would like to know if i’m going to be ok to wait till next month. I know I have waited far too long but now i’m scared that it’s too late. Thank you

    Reply
    • Dr. Kezirian

      It is normal to be scared before surgery. You should obviously be comfortable with the plan for surgery or any other treatment and should have all the opportunities you need to have your questions answered and be on the same page with everyone treating you.

      Reply

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