My experience and many research studies indicate that most patients with obstructive sleep apnea have what is often called multilevel obstruction. This term refers to blockage of breathing in both the Palate Region and the Tongue Region. Choosing the right sleep apnea surgery is based on careful evaluation of an individual patient and then weighing the risks and benefits of possible choices. Studies have shown that multilevel surgery for OSA can address both areas of the throat to produce more benefit than surgery on one area alone. But studies have only rarely addressed the risks of surgery because studies of risks have to be much larger to make firm conclusions because risks of obstructive sleep apnea surgery are relatively low.
If a patient needs a combination of procedures to address multi-level obstruction, a common question is whether to perform the procedures at the same time or separately. There are pros and cons to each approach. Generally, performing more procedures at the same time allows a patient to recover from these procedures once, decreasing the overall recovery time. The downside is that the pain and risks of complications like bleeding may be higher with multiple procedures performed together.
What Is the Evidence on the Risks of Multilevel Surgery vs. Palate Surgery Alone?
It turns out that I have been involved with two large studies that have examined this question specifically. The first study was performed during my time as a resident and fellow many years ago and examined the experience of the Veterans Affairs Medical Centers throughout the United States from 1991-2001. In 3130 patients undergoing palate surgery for sleep apnea, the risks of serious complications soon after surgery were 1.6%, with a 0.3% risk of significant bleeding (more than 4 units of blood). In a related study of the same patients, the overall risks of serious complication were greater for those with the following: severe (as opposed to mild to moderate) obstructive sleep apnea, obesity, or significant medical conditions prior to surgery (medical comorbidity). It appeared that the risks of complication were almost 5 times as high with combined palate and tongue surgery, as compared to palate surgery alone, but it was not possible to know whether this was due to other factors (like obesity or more-severe sleep apnea) or due to performing multiple procedures at the same time.
A recent large study was done with a team of sleep surgery experts from around the country, looking at a national medical insurance database that includes care for approximately 59 million people. From 2010-2012, 14,633 adults underwent palate surgery for obstructive sleep apnea. There were a couple of key findings. First, relatively few (less than 13%) had combined palate and tongue surgery. Over half had palate surgery alone, and another one-third had palate surgery in combination with nasal surgery. This may reflect that many surgeons are not trained to perform tongue surgery for obstructive sleep apnea–although it could be that they are just not convinced that it is helpful or that the patients were not appropriate for tongue surgery. As far as surgery risks, the combination of palate and tongue surgery increased the rates of bleeding (6% vs. 4%) and dehydration (4% vs. 2%) but were not associated with other complications that were examined.
The Bottom Line on Multilevel Surgery for OSA
Our research has shown that some risks may be greater with combined palate and tongue surgery, compared to palate surgery alone. However, neither study above could tell whether the risks of combined surgery were greater than the total risks of palate and tongue surgery when performed separately. Although we do not have perfect information, we do have more information to discuss with patients considering multilevel surgery for OSA.
The decision to combine procedures in a single setting or separate them is based on the most current research, a surgeon’s experience and expertise, and, most importantly, patient preferences. Sometimes combining procedures really is all about not being able to take enough time off work. Other times a patient is not as comfortable with the idea of recovering from combined surgery as from two separate recoveries that might be easier on them. Sometimes a patient may have medical concerns or other parts of their examination that make it safer or increase the chances of success to do the procedures separately.
Ultimately, there are no firm rules on whether to combine procedures or separate them in multilevel surgery for OSA, and I take one approach or the other in different cases. My job as a surgeon is to discuss what would be very reasonable choices with patients and present with the latest information so that they can make the decisions that are right for them.