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).
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.