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).

5A - Tonsillectomy for Sleep Apnea as First-Line Treatment in Adults
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.



0 thoughts on “Tonsillectomy for Sleep Apnea as First-Line Treatment in Adults

  • Joseph Tidwell says:

    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!

    • 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.

    • 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!

    • 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.

        • If you are not doing well with CPAP, you should at least consider surgery. The next step would be an evaluation to determine whether surgery – and what kind of surgery – might be best for you. Please feel free to contact me directly to discuss the specifics of your situation.

          • Kathleen, If you would like to schedule an appointment with me, you can contact our office. Please feel free to e-mail me directly with any questions or concerns. Eric

          • It wont cure your sleep apnea. Got a tonsilectomy, turbinectomy and septomplasty. Still have it and my levels are actually higher now. Was a llevel 8 before surgery, went up to a 11 after the healing process for surgery

          • Thank you for sharing your experience. I am sorry you have not had a good result. These studies show that those with markedly enlarged tonsils generally do very well after this kind of procedure. I am not sure how big your tonsils were, but you still do have mild obstructive sleep apnea. I hope you are now feeling more refreshed after a night of sleep, as this is actually more important than your apnea-hypopnea index number from a sleep study for mild obstructive sleep apnea. The reality is that sleep apnea surgery is not 100% effective. This is why I have focused my entire career in this field, with an emphasis on how we choose procedures and can try to predict results.

          • Hi! I had a tonsillectomy in 1988 when younger had lot of different infections in the military!!
            I was always with infections and bleeding . Since then I have mild obstructed Sleep apnea. In the present use cpap machine. Why dose this happen . I didn’t know that I could develop this condition. Also have chronic sinus, allergy’s ext. Thank You for your advice.

          • Dr. Kezirian says:

            Your sleep apnea is almost certainly not due to your getting a tonsillectomy 32 years ago. In fact, you may have had sleep apnea at that time, with the tonsillectomy helping reduce or eliminate it! Sleep apnea is more common as we get older, whether due to the natural aging process, weight gain that can occur with getting older, or something different. You still want to talk to someone about treatment now, but do not worry that you made a mistake years ago in getting your tonsils removed, ending up with sleep apnea as a result.

        • My ENT said my tonsils are enlarged and blocking passage…my sleep study Dr said I do not need the CPAP or surger for tonsils. My ENT wants to take my tonsils out…I think it said 4 on the sleep index, which they said was minimal sleep apnea but factoring in the blood oxygen levels it raised it to about moderate sleep apnea…my question is should I have my tonsils removed? I’m 37 …pretty sure I just need to lose 20 lbs….anyways thanks for any feedback, appreciate it!

          • Dr. Kezirian says:

            It is hard to make medical evaluations purely on the basis of limited information here. It is good that you are speaking to both a sleep medicine physician and otolaryngologist/ENT.

  • 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?

  • 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.

  • 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.

    • Dr. Kezirian says:

      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.

  • ricky woodruff says:

    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

    • Dr. Kezirian says:

      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.

  • Craig Smiles says:

    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.

      • Have an update, I got retested for my sleep apnea about a month ago and it would appear the tonsilectomy worked as I have gone from severe obstructive sleep disorder (rated level 15) to having no trace sleep apnea whatsoever.
        Message to all, there is hope and cures out there you just have to keep pushing the right people to get what you want.

      • One other piece of advice, if anybody out there does have their tonsils out whatever you do not eat tomatoes until you are fully healed. I did and I can say is I have never experienced pain like it. Stay well clear.

  • 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.

  • 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?

    • 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.

  • 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

    • Dr. Kezirian says:

      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.

  • Angela Tonkin says:

    My two year old had her tonsils and adenoids removed 8 days ago. She’s still waking up a lot. How long before her sleep improves?

    • Dr. Kezirian says:

      I do not treat children anymore. This would definitely be a good question to ask her surgeon. I wish your daughter all the best.

  • Kenneth leong says:

    Hi, i had enlarged tonsils n sleep apnea with very severe ahi of 93.
    Can enquire if having a tonsils removak improves my sleep apnea condition?

    God bless

    Kenneth leong

    • I am not sure of your question. Having very enlarged tonsils can be a reason for obstructive sleep apnea, including very severe disease. Removing them should help, but only your doctors can tell if this will be the right approach or if anything else should also be done.

  • Wow. This is so exciting. My dentist said I had massive tonsils. I have extremely severe sleep apnea, making me sleep all day too (like chronic fatigue syndrome).

    Now I can’t wait to get my tonsils out!! 😀

    Later tonsils! I know life is gonna be better!

    Hope its not too painful or expensive but whatever. Sounds so worth it. I really hope the surgery doesn’t kill me. I just wish they would have cut them out when they cut out my gall bladder…

    • It will be painful, but the pain typically lasts for about 10 days. However, you will be trading that pain for a good chance (depending on other aspects of your physical exam) or improving substantially or even eliminating your sleep apnea.

  • Barbara Schmidt says:

    I have extremely severe OSA. I am 60 and overweight. However, I cannot wear my CPAP due to a panic disorder. I’m having my tonsils removed and also having a dental device made. (My surgeon recommends both). I’m not looking forward to surgery, but I am looking forward to some better sleep.

  • Joanne Beckett says:

    Hi, what about adenoids? I’ve been having some night-time apnoea-type episodes, which are terrifying. I don’t have a diagnosis and I’m being passed round the departments. It isn’t reflux (had all the tests), and respiratory say I should get my throat checked. I inhaled some food in March and I think that might have been when this started. I’m not overweight and I feel there is something quite high up in the back of my throat that obstructs the airway at night. Could this be adenoids even though I am 50? I get a sore throat and lose my voice regularly every Christmas, and I’ve often had inflamed tonsils over the years. I’m also hypothyroid, although it’s managed with medication. I’ll be seeing ENT soon I hope…

    • Your plan of seeing an ENT/otolaryngologist for an evaluation is a good next step. Adenoid enlargement is not so common in adults, but it definitely is possible. I have performed adenoidectomy in some adults to treat blockage of breathing through the nose as part of treating obstructive sleep apnea.

  • I had my tonsils and adenoids removed September 20 2018. I am finally on the mend. I had bleeding issues so my surgeon went back in to re cauterize my throat. It made my healing phase longer but after a month I can say it was totally worth it. I have had severe sleep apnea, enlarged tonsils and tonsillitis since I was a teenager. I’m 36 now. It was painful but worth it. I don’t have sleep apnea anymore and I don’t even snore anymore. The only thing is everyone says my voice sounds really different.

    • I am so glad you are now doing well. Having a noticeable change in your voice is not common at all, as I have not had a patient ever experience this before, aside from going from what many people would call “nasal” speech (because the nose is so blocked) to more-normal and clearer speech. I expect this was related to the need to return to the operating room for bleeding, although even then I would say it is unusual.

  • I am having the worst time sleeping with my mask. I feel like I am suffocating with it on. I may get 2, maybe 3 hours a night. Should I bring up to my Doctor the tonsillectomy?

  • Hello to all,

    I’ve had a cpap device for a little close to 3 years now. My level is at a 9. Since using my cpap, i sleep well over 6-8 hours and I still feel restless. Although it’s easy for me to fall asleep, my body can’t seem to wake up on it’s own. I’m constantly having to snooze my alarm because i feel i need more rest. I feel my mask is on right without having to make any adjustments of improper air flow. Without my mask, i snore like no other and catch myself waking up due to it. I still feel restless. I’m 38 years old and I just want to know what it feels like to be rested. I feel there’s no way that i can sleep for those periods of time and yet still feel tired. Now, I want to see if removing my tonsils would make be the next step. Although, I’m no Dr., I do feel they seem enlarge and are very close to my uvula. Looking for some advice on here and want to see if people are having the same issues as i am. Thank you and Happy New Year.

    • There are definitely patients who wear CPAP but do not do well with it because they are not truly comfortable with it. They can end up waking up often during the night and obviously aware of not being comfortable with the CPAP mask on, but sometimes it is not quite as obvious. As you point out, the first step in considering surgery is determining what kind of surgery would be best for you and whether you would have a relatively high chance of clearing up your sleep apnea with surgery. Because everyone is different, I would recommend seeing someone who focuses in sleep surgery for an evaluation and discussion of your options. Please let me know if you would like to come see me.

    • Hi Aron,
      Do you mean to say that your CPAP is not making you feel refreshed?
      I have only recently been using a device since November 2018 A Resmed APAP (I’m based in Australia) and found it amazing. Recurring tonsilitis was the main reason why I decided to have a tonsillectomy and I am recovering now.
      I cannot say that I have big tonsils, but without them already (day 10 post op) it feels like my breathing is clearer and less restricted at all times. I suggest the pain and discomfort was well worth my simple surgery.

    • I am a singer. When I sing my tonsils are so big that they quite literally press on my tongue and ruin certain vowel sounds. It really makes it difficult. They rattle. Plus I have heavy sleep apnea and struggle with the mask. I want my tonsils gone. It’s depressing me into to a shadow of who I used to be. Is laser really better than the old school method? I’m not even sure the NHS will do laser. I’m 36. The surgery scares me.

      • I do not perform laser treatment, as I do not think it is better. There are special concerns in professional singers with tonsillectomy, as voice changes will occur. They can be favorable, as might be the case for you. You should discuss this with your surgeon.

  • Yasmin Magliocco says:

    My partner has been on CPAP for a year and a half and on surgery waiting list 2 years. He has obstructive sleep apnea and the largest tonsils his surgeons have seen. Finally got a date for surgery, this Friday, I can’t wait to see if it helps. Before CPAP he had 78 apnea per hour and with CPAP he is down to 5 but the machine depresses him and he hates using it as it leaks and he is still tired every day.

  • After suffering with severe CPTSD I was so hyper-aware I could no longer sleep through my snores. Every time I’d start to dose off my snoring would wake me up. After being hospitalized for suicidal ideation because of the snoring issue I was finally put on a CPAP with a nose pillow mask that wraps around the back of my ears. I use that kind because I have horrible pain in my head if anything touches it, including bobby pins! (This from a head injury in 1984) However, it is very hard to sleep even with that mask as it hurts my head behind my ears. I’ve fashioned a fancy doughnut shaped pillow that helps sometimes. I’m very aware of how I snore because I’m so hyper aware of it. It seems that most of my snoring comes from the sides of my throat where my tonsils are. And now that I’ve lost a significant amount of weight I can sleep sitting in a recliner without worry of snoring. However, back when the issue first started in 2016 I saw an ENT who didn’t see that my tonsils were enlarged. I would like to get off of my CPAP so I’m trying a SomnaMed devise but still get awakened by snoring sometimes for reasons unknown (except whenI awake on my back). And I’m concerned with long-term use because I have an overbite and very short grinding teeth, and TMJ issues and I hear the devise can cause repositioning of your jaws. Because this is such an issue ( psychologically and physically) do you think I might qualify to get the surgery even if the tonsils are not enlarged? If you think I might do you have any suggestions on how to approach my doctors about it?

    • Dr. Kezirian says:

      You absolutely could qualify for surgery, including the array of options that goes beyond tonsillectomy. You should discuss the potential benefits of surgery with your sleep medicine team and consider seeing a surgeon (usually would be an otolaryngologist or ENT).

  • Hello,
    I am Ashley. I have had chronic tonsillitis (12 times in the last 2 years) and their enlargement had caused me severe sleep apnoea.
    I have just had a tonsillectomy on 20/2/19.
    There is a lot I would like to share if anyone has questions. One quick observation here that has surprised me was peoples thoughts of the APAP Machine. I love mine but I’m not allowed to use mine until the risk of bleeding goes down (normally after day 10) this was according to the surgeon anyways.
    So my question to the experts Does using an APAP increase the chance of a post tonsillectomy bleed?

    • Dr. Kezirian says:

      I actually love it when my patients can wear APAP or something similar during recovery from sleep apnea surgery. It is usually not possible because patients are havnig surgery often because they are not doing well with APAP or other forms of positive airway pressure therapy. As far as risks of bleeding, I would not think it would raise the risk, but I guess it could theoretically lead to dryness and cracking of the healing area.

    • Ashley,
      As I am going to be undergoing a tonsillectomy soon, I am very interested to hear about your experience. Could speak via email?

      Did you have a normal tonsillectomy or an intracapsular tonsillectomy?

  • Hi there. I’ve recently been diagnosed with mild sleep apnea. I have had large tonsils for most of my life but they are finally causing me distress at night. I am scheduled to have them taken out in a couple of months and am very anxious about the surgery. I have heard this can be very painful for adults. My surgeon plans to complete an intracapsular tonsillectomy rather than the traditional tonsillectomy. Have you had luck with this procedure? I worry about infection in the tissue that will be left. Is it rare for the tissue to grow back in adults?

    Also, how do your patients normally rate post-operative pain? While I want to have the surgery as I feel this will help my sleep apnea tremendously, I worry that I am going to go through this pain for nothing.

    • Dr. Kezirian says:

      I do not perform intracapsular tonsillectomy myself, as I remove the tonsils entirely because this seems to have a lower rate of growing back. Tonsillectomy in adults is extremely painful for about 10 days, but you have to weigh risks and benefits of any procedure, trading off this pain for the benefits of the procedure. Good luck.

  • I suffered from sleep apnea until my late thirties. Finally, by the time I was diagnosed, I have developed type 2 diabetes. I have a normal weight. I got on CPAP and it was affecting my ability to camping, travel etc.. I got my tonsils removed in Asia in a private high-end hospital for $2,000 (costs less than what I spent on my CPAPs) and all my sleep apnea is gone. I highly recommended for anyone with enlarged Tonsils. Your life changes with this surgery. I wished my stupid GP would have recommended my tonsils be removed as a kid (because of multiple reoccurring infections each year due to sleep apnea and mouth breathing) like that of my brothers’ GP. They both had their tonsils removed as a kid. I would have not developed diabetes due to sleep apnea if I had the same surgery as a kid.

  • Janet Greenlee says:

    I have been diagnosed with severe sleep apnea. With the cpap machine my AHI ranges from 20-47. Does this mean the machine is working or is not working. Sorry for this probably dumb question. I used sleeping pills for years to sleep. Now I don’t use sleeping pills but I have never gotten a good night’s sleep with the machine. I am ancient— 73. I wonder if I’m too old to have my tonsils etc out.

    • Dr. Kezirian says:

      The first step is to follow up with your sleep medicine physician. Although the AHI measured by a CPAP machine is not the same as the AHI measured on a sleep study, an AHI of 20-47 from a CPAP machine is not normal. Someone should evaluate why your AHI measured by the CPAP machine is so high, potentially having you obtain an in-laboratory positive airway pressure (PAP) titration study. If it proves impossible to treat your obstructive sleep apnea with PAP, you may consider surgery. The age of 73 is not ancient, as you certainly still have your sense of humor.

  • I appreciate this forum and all the comments about personal surgical success. I have obstructive sleep apnea and considering surgery for a deviated septum and large tonsils. I’m 42, average weight, and the CPAP was not working for me. The comfort of wearing the mask was fine but I felt like it took too long for the small pump to get me a large enough volume of air when I needed a big breath and was suffocating and had to constantly take it off to breath, then put it back on. The technician (I think they work for the Manufacturer of the CPAP) was dismissive and insisted that it works fine. I gave up on it but having a lot issues (like high blood pressure now) and scared the sleep apnea is going to kill me. Need to get this done. I was told I’d be a good surgical candidate but want to be sure I go with someone well versed in this area of surgical options and the various specifics. Dr. Kezirian: You seem to be very knowledgeable but in L.A? I’m in the Midwest. Any experts/surgeons you’d recommend near IL or MI?

    • Dr. Kezirian says:

      I have tremendous respect for sleep technicians and respiratory therapists, as they work for the centers and not for specific manufacturers. I understand your frustration, however, and the issue is that CPAP is not always a simple solution for every patient.

      Please e-mail me directly with your question.

  • I am a 55 year old woman of normal weight. I was diagnosed with moderate sleep apnoea and have since been using a new generation mandibular device. I have responded fairly well and a subsequent sleep test showed an AHI of 11 – mild sleep apnoea. However, I am not keen on the prospect of having to wear the oral device every night forever and certainly would prefer to avoid the CPAP machine. So, I went to see an ENT to investigate surgical options. It turns out I have a floppy soft palate and I have been booked in for a tonsillectomy and palatoplasty. My ENT dutifully went through the associated risks during our consultation and it all seemed reasonable at the time. However, since the consultation, I have received consent forms to sign and those same risks, written on paper, look more worrying! Furthermore, I (foolishly?) did some internet research and came across an abstract that mentioned significant morbidity/mortality rates in patients who underwent a palatoplasty ( the subset who suffered from OSA)! I have booked another consultation with my ENT prior to surgery to address my concerns however, I would love your opinion too. I am a part time jazz singer and my initial worry (based on the consent documentation) was that my voice could remain nasal beyond the healing period. Now I have a more significant concern – based on that pesky abstract – I could choke and die either during the surgery or afterwards! Perhaps I should just be happy with the improvement achieved with the device.
    I plan to ask my doctor for percentages regarding those 2 concerns. I am trying not to think about the pain!

    • Dr. Kezirian says:

      The risks of any surgery do include death, but your surgeon can discuss the risks in more detail. I was fortunate to be involved in a large study looking at serious complications after sleep apnea surgery (it was mainly soft palate surgery at the time), and they were 1-2%, with a risk of death within 30 days after surgery of 0.2% (1 in 500). What is more important than these overall numbers is the fact that the risks were most clearly associated with significant medical problems prior to surgery, such that patients who were reasonably healthy and undergoing sleep apnea surgery had a fairly low risk of these serious complications.

  • Although, I am curious on your opinion. My pcp doctor helped me get diagnosed with sleep apnea last year. I have recently had to get retested and found it had gotten worse + RLS. My pcp has pushed for my tonsils out but, the ENT said I didnt need it. Now, after the second test. The sleep center doctor has also recommended it so, now I have 2 for because of sleep apnea results and tonsils are large and 1 against because he says they are not that big. Who to believe is the question? I’m desperate to feel better but, not wanting to have unnecessary surgery.

    • Dr. Kezirian says:

      Tonsillectomy involves cutting through blood vessels that supply blood to the tonsils, so cutting through blood vessels is a necessary part of the surgery. Bleeding can occur after tonsillectomy, typically either in the first 24 hours or at 5-12 days after surgery. There are different reasons for bleeding, but the bleeding can be significant, especially if it comes from an artery (even the small arteries that must be cut during the tonsillectomy). I am not sure if this answers your question.

  • I am 59 years old and suffer from severe sleep apnea. I stop breathing 105 times per hour. I tried an oral device, cpap, bpap, and vpap without success. Three years ago I went to the Mayo clinic and had mandibular surgery. The surgery did not improve the number of times I stopped breathing but, I do feel a slight improvement in my sleep. My surgeon recommends I have the same surgery again to move my jaw further. I will not do this as I don’t want to do more damage to the nerves in my mouth not to mention more pain(still to this day). When I had my last study I felt like the resistance was more in the back of my mouth. My tonsils where never brought up.Should I bring it up? Is there anything else I should look into?

    • Dr. Kezirian says:

      Mayo Clinic tends to move directly to maxillofacial surgery for treatment of sleep apnea without considering other surgical options when patients do not tolerate CPAP (and other forms of positive airway pressure therapy). Especially given that you did not have improvement with the mandibular surgery and what may be postoperative nerve-related pain, you are right to think about whether other approaches might make sense. I would recommend seeing a sleep surgeon who can discuss other choices in more detail. I would be happy to see you over telemedicine (or in person once we are back to normal operations) to discuss these other approaches.

  • Linda Louise Buscemi says:


    • Dr. Kezirian says:

      The aerosol potential from CPAP would mostly affect others, not you. The concern is that, if a CPAP user has SARS-CoV-2 (the virus that causes COVID-19), then their use of CPAP could create aerosolized particles that could infect others. I honestly do not know how significant the risks are to others, but I do know that it would not be that you are putting yourself at risk by using CPAP. CPAP can contribute to inflammation in your nose and other respiratory infections, but this is separate from the discussion about CPAP and aerosolized particles.

      • Dr Kezirian
        I live in Melbourne Florida and was diagnosed with mild sleep apnea and sleep dr recommended CPAP which I have been using for almost 3 weeks but I
        must say that my sleep quality did not improve and still wake up at night with severe headaches. Could you please recommend a clinic or Dr near the Melbourne area to consult on the Tonsillectomy
        thank you

        • Dr. Kezirian says:

          I do not know anyone there, but I do online consultations. These are not billable to medical insurance because you are in a different state. I can provide the same service but would have to charge you. Please contact me directly if you are interested.

  • What about people who have cleft palate? I was told a long time ago I could never have my tonsils removed. I have a repaired complete bilateral cleft. Now I am 46, and suffer from tonsillitis up to 2-3 times a year. Ever since the surgeries to close my hard palate at age 30, I have not been able to breathe through my nose at night. Not knowing that it would effect my ability to get life insurance, I conceded to a sleep study due to insomnia. Now they want me on CPAP. I struggle with the CPAP worse than the insomnia. I was not tired during the day before the sleep study. The latest ENT is also afraid to remove anything because it might impact my speech.

    • Dr. Kezirian says:

      This is definitely tricky, but you can have your tonsils removed even with a cleft palate. It is just that the risk of speech and swallowing problems are greater. In general, your surgeon would likely not do anything to your soft palate because that would increase the risks further, but every case is different. You would certainly want to discuss this with a surgeon.

  • Hi! I’m 49 15-20 lbs overweight. I don’t think weight is a factor as this started prior to weight gain. Had my tonsils removed and part of my uvula December 2019 for both enlarged tonsils and reoccurring strep. Snoring decreased to almost none but over the last 2 months it’s gotten back to where it was to start. I do NOT want to go back to CPAP. Are there any other options??

    • Dr. Kezirian says:

      There are many possible explanations for this and many posible options. You would have to discuss them all with your doctors to get more specifics.

  • Hi my name is Mike,
    I was diagnosed with sleep apnea back in 2017. I just recently had bloodwork done which showed that I have elevated RBC’s and hemoglobin. My PCP wasn’t concerned about it since I was barely over the normal ranges. My question is could The parameters of my cpap not be set up properly and that’s what could possibly be causing my increase in RBC and hemoglobin?

    • Dr. Kezirian says:

      There are many potential causes of high levels of red blood cells and hemoglobin/hematocrit. Untreated or partially treated obstructive sleep apnea is one explanation. My guess is that you would want to monitor with a repeat blood test at some point. It may also be a good idea to check with your sleep medicine physician (whoever prescribed the CPAP) to see if your sleep apnea seems to be treated well.

  • Hello,
    I am 19 and was diagnosed with severe sleep apnea January this year (stopped breathing 40 times in very hour) during sleep study. I’ve been using the CPAP machine for about 3 months and found it to work greatly however absolutely hated it.

    My ENT sorted out for a tonsillectomy and adnoidectomy as I have grade 4 adenoids and very enlarged tonsils.

    It’s been over 3-4 weeks since the surgery and I tried sleeping without the machine, however believe that I am snoring really bad and wake up feeling really tired. So I’m using the CPAP machine again. My voice has changed slightly and I don’t sound as nasally anymore.

    Is there any chances that the surgery can make sleep apnea worse?

    He said it could take up to 3 months to feel the full affects.

    • Dr. Kezirian says:

      Your surgeon is correct, in that in can take time to notice benefits. Based on what you said, things should not be worse unless you had unfavorable healing (not likely if you just had tonsillectomy and adenoidectomy). At 3-4 weeks, you should start noticing some benefit of the procedure, although even once you fully heal, you may still have some sleep apnea, making CPAP still helpful. However, I really would expect your sleep apnea (and breathing during the day) to be better without the CPAP.

  • If OSA is an anatomical issue, why don’t young adults have problems as often as older adults? What changes? It sounds like it can’t solely be due to age-related weight gain as losing weight should cure the problem if it were due to obesity, and plenty of normal weight people need a CPAP.

    • Dr. Kezirian says:

      This is a great question. There probably are age-related changes other than weight gain (tissue laxity, aka the same process that causes skin wrinkles). We just do not understand these completely yet. As far as OSA in those with normal body weight (about a third of individuals with OSA), this can be due to numerous reasons, whether something as basic as enlarged tonsils, a small lower jaw, or getting somewhat older.

  • Juanita Aydlette says:


    I have been on C-Pap for 16 years. I have always had problems with my nasal cushion and have taken Benadryl to help me sleep. I suffer from sore spots on my face from the cushion. I was told that I stopped breathing 101 times during my sleep study,
    My throat closes up even if I’m very comfortable while watching TV. My jaw super relaxes and blocks my breathing. I never told the doctor that part. My tonsils have been large since I was about six years old, I am 63. Am I making a mistake, waiting so long to now want my tonsils out?

    • If your CPAP is working well, then you should keep wearing it. However, you may also want to see a surgeon to discuss the pros and cons of surgery in your case. Large tonsils, by themselves, do not need to be removed. Instead, the decision to remove them should be based on the risks and benefits of surgery.

  • Without a shadow of a doubt if u have enlarged tonsils and use a cpap machine and don’t benefit from it .it’s a real high possibility that your enlarged tonsils are blocking your air and what is possibly causing your sleep apnea.even if u are using a cpap machine chances r your enlarged tonsils r blocking air.i had high blood pressure I could never control with 4 different pills .none could control my blood pressure.if u wake up tired it’s probly because of your narrow throat is being blocked from your tonsils.also just cause the cpap machine shows that you have less apneas on the chart or on a study it doesn’t mean you r getting the air u fully need to start your day off with .I had enlarged tonsils and even with cpap I never felt fully rested I tried the mouthgaurd with cpap .it did help a little the 1st few days I felt really exhausted then after about the 6th or 7th day I felt more alert .but still had high blood pressure .then I tried the toungue device that pulls your toungue with the help of the suction .it’s kinda painful but I definitely felt a difference when I woke up the next morning .I felt definitely more alert .I just wish I could have felt like that everyday.i went to the ear, nose, throat specialist and saw I had a 4 on my tonsils meaning they were obstructing my air .I can only imagine what it will b like when I cut out my tonsils. I plan on getting them cut out .without a shadow of a doubt I am pretty sure when u get those tonsils pulled out there will b a significant change for most people .everybody is always gonna have a different opinion on tonsils but if u have severe sleep apnea and large tonsils I would definitely start there.also if u have a deviated septum restricting air I would also get that fixed .it will help alot .chances r your blood pressure will slowly go back to normal or at least get more controlled with pills ..I guess I could say I have tried alot of things to try to get back to normal .one thing is for sure if u have high blood pressure and u happen to have enlarged tonsils or a deviated septum or both .I would definitely get them both fixed .there’s a possibility I lt could b the cause for it.doctors will always have there doubts about if it will help fix your blood pressure ..if u feel it could b the cause of it chances r u could b right .. every doctor is different and has there own opinion. I have heard plenty of opinions from doctors one says yes .one says no. About tonsils being enlarged blocking your air In the throat. I have talked to sleep apnea specialist .each one of them always has a different opinion about enlarged tonsils .I’m no doctor but I have tried different things to help with my sleep apnea and one thing for sure is start with tonsils and nose .I just want to let anybody know that sleep apnea can be caused by a number of things but don’t leave out tonsils that could b causing your sleep apnea .if u have a gut feeling telling u that it could b the cause then I would go with it

  • Devin Huskey says:

    Dr. Kezirian,

    My wife is telling me that I stop breathing in my sleep. I’m considering a sleep apnea machine or getting my tonsils removed. I have no clue as to what route I should pursue. I plan on seeing a professional in person tomorrow. Please provide your insights on what you think and your recommendations. Thanks in advance. I really want to try the sleep apnea machine first. I’ve never had surgery as a 26 year old man.

    • Dr. Kezirian says:

      You will likely have a sleep study as a first step. If you have sleep apnea, you will need to try the CPAP machine first unless there is another reason to remove your tonsils like chronic tonsillitis. Please let me know if you would like to discuss this in detail with me during a video consultation.

  • Jacob deleon says:

    I need to ask a question does enlarged tonsils effect cpap use.i can’t get my blood pressure under control .my doctor for the ear ,nose,and throat specialist said I have a 4 on and a 3 on my tonsils .he said yes it blocks my air .but he is not sure if it is the root cause of why I can’t get my blood pressure under control.i plan on getting the surgery for the tonsils being cut out.i am not a doctor but I think it makes sense that having enlarged tonsils could be the cause of my high blood pressure .I use cpap but I never really feel it helps .I have a feeling that if I get the tonsils taken out I will benefit from the cpap machine and my blood pressure will b more controlled .my blood pressure stays on 150/90 .it’s like it’s stuck there cause I don’t get the air I need from cpap.i figured cpap would work but I need a opinion that having enlarged tonsils doesn’t give me the air I need cause of enlarged tonsils

    • Dr. Kezirian says:

      Large tonsils can increase the CPAP pressures required to treat your sleep apnea, and that can affect your comfort level with CPAP. However, large tonsils themselves should not prevent CPAP from being able to treat your obstructive sleep apnea, as long as you are able to sleep comfortably while wearing CPAP.

  • Terri A Dood says:

    Hi Dr. K, my name is Terri. I am new to all of this sleep apnea world, I have a moderate case, recently diagnosed in February 2021. My family physician has taken over my treatment as the sleep specialist doesn’t have an open follow up appointment until November! Anyway, my MD had never heard of a toncillitomy helping with sleep apnea as the specialist said it may be an option. Is there a website I can direct my MD to? This is my first preference as it seems more of a permanent solution. Right now, I have been on a CPAP for a month, and am getting less sleep than before! Not only is my husband still wearing earplugs, but now I am as well. I can’t stand the sound of the machine, it seems so loud at night! I have also heard of a trial that sends little zaps from a surgical treatment that Stanford is doing. Do you have any knowledge, and/or, opinions of this procedure? Thanks in advance.

    • Dr. Kezirian says:

      You can refer them to my website, of course. The treatment is called Inspire Upper Airway Stimulation. We were the first center in the Western US to offer it to patients, and I also have a page describing it on my site.

  • My husband recently finished a bodybuilding competition (his 3rd one in the last 4 years). And this time he us having a terrible time sleeping. Notable sleep apnea with loud bursts of snoring waking him, extreme dry mouth, high anxiety due to inability to breathe well, and extreme sleepiness throughout the day due to lack of sleep at night. He still works out daily and follows a pretty strict diet and has a very low body fat percentage. Have you ever heard of bodybuilders having increased issues, especially post competition when they start to incorporate more normal foods back into their diet? Just wondering if you or anyone has noted any correlations between the two?

    • Dr. Kezirian says:

      I am not aware of studies on bodybuilders, but I am not surprised. Obstructive sleep apnea is more likely with increased body muscle mass, as the increased muscle mass also generally includes the head and neck (with musculature of the tongue, for example, larger in size). We see obstructive sleep apnea as common in individuals taking supplemental testosterone or other hormonal treatments that increase muscle mass. Studies have been done of NFL football players, showing a high proportion with obstructive sleep apnea.

  • Hi Dr K, I have just recently {6 days ago} had a tonsillectomy and UPPP surgery.
    I don’t actually know if I have sleep apnea as I have never had a sleep study but I do suffer from loud snoring and have done so for most of my life. I’m 50 now and quite substantially over weight but even in my teens when I was in the healthy weight range I was a snorer.
    My tonsils were graded at stage 4 and my uvula seemed to be enlarged as well. I am keeping everything crossed that this surgery will have worked for me and will provide me with relief from my constant snoring and ongoing sore throats.
    My question is how long will it be before I should expect significant reduction in my snoring? How much healing time is required for the swelling etc to go down post surgery.
    As a side note people say that the UPPP surgery and tonsillectomy are extremely painful during the recovery and I can certainly vouch for that. Wow day 6 and the pain just keeps coming! This surgery is certainly not for the feint hearted.

    • Dr. Kezirian says:

      You should talk with your surgeon about the timing. Many patients with markedly enlarged tonsils will notice an improvement in breathing right after surgery, but usually we wait until at least 3 weeks from surgery to see any substantial benefit. The important thing is the long-term results, and you are basically trading substantial pain (although you should receive medications to help with that quite a bit) for the first 1 1/2 to 2 weeks for the chance to get some high-quality sleep.

  • I’m male, early thirties. Found out that I have sleep apnea about a year ago after feeling chronically fatigued for years and not knowing why (not to mention the other psychological effects of chronic sleep deprivation).

    The first sleep center I went to was Common Sleep. I did a home study that was negative for apnea, then a PSG (polysomnogram or in-lab study) – also negative. My AHI was 4.1 on the PSG and the report said I had “25 spontaneous arousals per hour”. I questioned the doc on this saying “doc, that sounds like a lot” to which his response was “that’s normal”.

    Not feeling entirely satisfied, I started educating myself. I learned more about sleep studies and how they’re scored. I learned that, in a way, the scoring is somewhat arbitrary. I learned that AHI does not necessarily correlate well with severity of symptoms. I learned about the difference between 1A and 1B hypopnea (and that my PSG had been scored with 1B hypopnea which is essentially a poorer criteria). I learned about RERAs. I then had my study rescored with 1A hypopnea and the results was AHI and RDI both were 9.3 (the fact that they were both the same made me suspect that RERAs were not scored appropriately).

    Still not feeling entirety convinced I did a WatchPAT (home sleep study off Amazon which gave me AHI of 7.2 and RDI of 14.6), and then I went to Texas to do a second PSG with a respected sleep doctor who used esophageal manometry (PES). The resultant AHI was 23 and RDI 33.5.

    Quite clearly I have moderate to severe sleep apnea. However, I walked in and out of asleep center after TWO tests without being given any kind of a diagnosis, whatsoever. I’ve had to fight for this, and I’ve questioned my sanity and wisdom at every turn due in large part to feeling gaslit by the first doctor I worked with (who I’m sure had my best interests at heart, but who was also woefully undereducated). It’s been a long road for me but it feels so good knowing that there’s an explanation and a name for the suffering I’ve endured for the past several years.

    Just two weeks ago I took the first major step toward treatment of my sleep apnea – tonsillectomy. I had tonsils that were scored at grade 3 (at least) and as such were quite enlarged. At this point I can’t say I’ve noticed any appreciable improvement to my sleep but it may be too early to tell. However, I’m prepared for the fact that it may not help much at all; I see it as a necessary prerequisite given their abnormal size – it was the right decision whether or not it ends up helping.

    Beyond tonsillectomy I’m looking at MMA. My preference is to avoid as much soft tissue surgery as possible (no offense Dr. Kezerian), however, I’m always open to ideas. I know that I have craniofacial deficiencies (I’m retrognathic) and could likely benefit substantially from such a procedure. I’ve already consulted with one orthognathic surgeon who has said that I’m a good candidate for MMA. And I’m going to consult with at least a couple others. This is all still in the early stages but I’m looking ahead to the future in case tonsillectomy isn’t essentially curative (which I’m not expecting it to be).

    Anyways, just wanted to share my experience thus far. Sleep apnea is a terrible disease and is poorly understood by not only the public at large but also many actual sleep doctors. It’s unacceptable that there’s essentially a 50/50 chance that a relatively young, otherwise healthy, non-obese person might walk in and out of sleep center without ever getting diagnosed when, in fact, they have obstructive sleep apnea that may be severely impacting their life. I hope to see sleep medicine continue to advance and for diagnostic criteria to become more inclusive and standardized. Dealing with the symptoms of sleep apnea is hard enough as it is – I shouldn’t have to become an expert.

  • I am 33 year old female that is obese (270lbs) but slowly loosing (down 30# so far). I was diagnosed with moderate sleep apnea (20) and am not able to do CPAP due to panic attacks with the positive air pressure and feelings of suffocation unfortunately. I am now suffering from severe insomnia. Saw an ENT specialist and was told that my nose and mouth were quite small and my tongue quit large with tonsils at a 2+ bilaterally. He suggested removing tonsils as well as fixing some nasal narrowing with microablation(???) to my nose and back of tongue. I’m worried about surgery/recovery because of my size and wondering how I will be able to breathe afterwards with my nose and throat being worked on at the same time. Any advice and insight welcome to ease my mind as I see this as being my only option to break this insomnia and help my apnea.

    • Dr. Kezirian says:

      Losing weight before surgery can make surgery safer, less-involved, and more-effective. I would generally recommend losing the weight that you can safely and remaining in contact with your team. Many patients with untreated sleep apnea find it very difficult to lose weight, but if someone is overweight and can lose weight, it is a good idea to do it before surgery.

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